ࡱ> Aiu n F q&bjbjt+t+ AAY]$P$>nF0v""$-%L\^^^^^^$eYuy%!"y%y%wJFwJwJwJy%:\y%\wJwJQr` p6\ L`"</:H":Active exercises and prevention of progression of an idiopathic scoliosis.  Carsten Pedersen Morten Lund Andreas Paulsen Christine Larsmon General supervisor: Eddy Salters Methodological supervisor: Annelies Simons Research report Fontys University of Professional Education Department of Physiotherapy Date: 300502 We have found too many examples of how enthusiasts can be deceived in their appreciation of their own success and how accomplishments are far removed from hopes desires from realities. It is hard in such a case to recognize that one has deceived himself, but it is a sacrifice of the ego that the greatest have not blushed to make for science. Malgaigne, 1843. Foreword All students are requested to write a graduation project before ending the physiotherapy study at Fontys University of Professional Education in Eindhoven. The members of this project group, Carsten Pedersen, Andreas Paulsen, Morten Lund, and Christine Larsmon made a proposal for the graduation project. The result of the proposal was a descriptive research entitled, Active exercises and prevention of progression of an idiopathic scoliosis. The subtitle was; A comparative analysis of the importance of detecting adolescent idiopathic scoliosis, and the effects of active exercises and bracing in treatment and prevention of progression of an adolescent idiopathic scoliosis. The contents of this descriptive research will include a data analysis and synthesis of articles about screening and treatment of adolescent idiopathic scoliosis. The project wants to answer what are the interventions for detecting adolescent idiopathic scoliosis as early as possible, and what are the effects of active exercises and bracing on a patient with adolescent idiopathic scoliosis in relation to preventing progression in degrees of the curve(s). The members of the project group became interested in the topic on the basis of lack of experience from their clinical affiliation periods in Norway. The fact that adolescents with idiopathic scoliosis have limited opportunities to get sufficient help made the members of the project group eager to increase their knowledge within this field. The opinions regarding both screening and treatment of adolescent idiopathic scoliosis are diverse, and it was found necessary to try to collect and clarify the information existing in this field of health care. It is of interest to the project group to work with adolescents with idiopathic scoliosis in the future, and a need to increase the knowledge concerning the physiotherapists role in relation to treatment of adolescent idiopathic scoliosis. Taking these aspects into consideration, the members of the project group saw the demand for a thorough analysis of the information concerning screening and treatment of adolescent idiopathic scoliosis. The members of the project group want to give their special thanks to Eddy Salters, the general supervisor and Annelies Simons, the methodological supervisor. In addition their thanks go to Svein Ivar Olsen for giving information about scoliosis treatment in Norway, Jan van de Braak for giving information about the side-shift therapy at Sint Maartenskliniek in Nijmegen, and Anne Guro Larsmon for help with the illustrations and lay-out. The project group also wants to thank all students, teachers, friends, and family for all the support they have given each member during this project process. Eindhoven 300502 Carsten Pedersen Andreas Paulsen Morten Lund Christine Larsmon Summary Objectives Among the treatment alternatives for adolescent idiopathic scoliosis (AIS) in Norway, only bracing and surgery are mentioned as generally accepted forms of treatment. There exists a lot of controversy on this issue; therefore a descriptive research is used to highlight the different aspects concerning the subject. The project group wants to focus on AIS from a physiotherapeutic point of view and try to investigate if other countries have a different approach on this subject. The objectives of the project were to find interventions used to detect adolescent idiopathic scoliosis, and the different treatment interventions used on an adolescent idiopathic scoliosis to prevent progression of the curve. The importance of early detection of idiopathic scoliosis and what other interventions that can be carried out instead of surgery have been highlighted. The physiotherapy role concerning the treatment has also been focused on. Before handling the questions concerning screening and treatment, background information on idiopathic scoliosis was written to make it easier to interpret the analysed articles, and make the reader understand why disagreements concerning the different screening methods and treatment interventions exist. Method The method used for the project was a descriptive research. Copies from 46 articles/books were gathered. All the information collected made the project group capable of comparing and discussing the different aspects of the objectives of this project. Literature was selected after thorough considerations by using inclusion and exclusion criterias and a data extraction list. The material was assorted into a theoretical framework and a descriptive research (including the results, discussion and conclusion). The theoretical framework gives a thorough description of an idiopathic scoliosis, screening, and treatment of adolescent idiopathic scoliosis. In the descriptive research the findings from the articles reviewed are included. This research was carried out to find the value of screening and different treatment methods of adolescent idiopathic scoliosis. These results were analysed by the project group in the discussion part. The project group paid a visit to the Sint Maartenskliniek in Nijmegen to get information from an expert in the field about the side-shift therapy for adolescent idiopathic scoliosis. Expert comments were also included from an interview with an orthopaedic engineer in Norway. Results The results from the descriptive research answered the two main questions of the project. The descriptive research shows that school screening is carried out to enhance early non-operative management of scoliosis to effectively arrest a progressive spine. The measuring instruments used to assess the magnitude of the progressions of curves have been questioned regarding their reliability. This goes for the use of the scoliometer, the Adams forward bend test as well as the Cobb method. Still these measuring methods are universally accepted. From the articles reviewed, bracing has shown to be the most effective treatment alternative. In general the results of the effect of treatment for adolescent idiopathic scoliosis show a low reliability. Conclusion There is a great variance of treatment forms for adolescent idiopathic scoliosis, and the disagreements on the effects of the treatment methods are even greater. The project group can conclude with the results found from the articles. The all-over interpretation of the articles is that full-time bracing gives the best effect in preventing the curve of adolescent idiopathic scoliosis progressing. The treatments with active exercises are most probably of a good concern for the patient, but little research and testing on exercises have been done, and the exercises come up with less effective or varying results for the patients. Taking these results into consideration, the project group feel capable of stating that the conclusion from the project group coincide with the conclusions from most of the articles. Further research on adolescent idiopathic scoliosis, its screening and treatments methods to find the most effective and ideal way of halting the progression or even improve a scoliotic curve is required. Keywords: adolescent, idiopathic, scoliosis, treatment, screening, bracing, effect. Table of content 1.1Introduction1Part 1Theoretical framework2.1Scoliosis.....22.1.1Introduction..22.1.2Structural and non-structural scoliosis.22.1.2.1 Structural scoliosis...32.1.3Primary and secondary curves.32.1.4Forms of idiopathic scoliosis...32.1.4.1 Infantile idiopathic scoliosis42.1.4.2 Juvenile idiopathic scoliosis42.1.4.3 Adolescent idiopathic scoliosis53.1Adolescent idiopathic scoliosis...63.1.1Introduction.63.1.2Aetiology.63.1.3Curve patterns and location.73.1.4Symptoms and complications..103.1.5Measurement tools..113.1.6Progression.124.1Screening of adolescent idiopathic scoliosis..144.1.1Introduction.144.1.2Reason for screening144.1.3Arguments for and against screening..144.1.4Screening staff.154.1.5Screening methods...154.1.6Referral175.1Treatment of adolescent idiopathic scoliosis..185.1.1Introduction.185.1.2The different treatment interventions.......................................185.1.2.1 Bracing195.1.3Exercise treatment for adolescent idiopathic scoliosis235.1.3.1 Exercise treatment according to Schroth.255.1.3.2 Exercise treatment in combination with bracing.265.1.3.3 Side-shift therapy.285.1.4The role of the physiotherapist31Part 2Descriptive research6.1Descriptive research about articles on screening and treatment of AIS.326.1.1Introduction.326.1.2Method of the descriptive research..327.1Results.357.1.1Introduction.357.1.2Screening.367.1.2.1 "A study of the diagnostic accuracy and reliability of the scoliometer and Adams forward bend test."..37 7.1.2.2 "Screening for idiopathic scoliosis."38 7.1.2.3 "An evaluation of the Adams forward bend test and the scoliometer in a scoliosis school screening setting.".397.1.2.4 "School screening for scoliosis."..407.1.2.5 "The efficacy of school screening for scoliosis..417.1.3Treatment437.1.3.1 "Effectiveness of treatment with a brace in girls who  have adolescent idiopathic scoliosis."..........437.1.3.2 "A meta-analysis of the efficacy of non-operative treatments of idiopathic scoliosis."..447.1.3.3 "Adolescent idiopathic scoliosis. The effect of brace treatment on the incidence of surgery."457.1.3.4 "Adolescent idopathic scoliosis: Treatment with the Wilmington brace.".457.1.3.5 "Effect of exercise, bracing and electrical surface stimulation on idiopathic scoliosis: a preliminary  study."...457.1.3.6 "Influence of an in-patient exercise program on  scoliotic curve. "467.1.3.7 "Treatment of idiopathic scoliosis with side-shift therapy: an initial comparison with a brace treatment historical cohort."..468.1Discussion and conclusion..488.1.1Introduction.488.1.2Screening.488.1.3Treatment.508.1.4 Conclusion539.1Limitations of the project549.2What could have been done differently regarding the project?..549.3Recommendations for further research..5510.1Literature references5610.1.1Literature references for Part 1; theoretical framework...5610.1.2Literature references for Part 2; descriptive reserach..............5810.1.3Recommended literature..5811.1Appendices.59Appendix 1Definitive FLP-format.60Appendix 2Questions for visit to Sofies Minde and Sint Maartenskliniek....75Appendix 3Data extraction form76Appendix 4Description of the literature search and the used databases.80Appendix 5Overview of the analysed articles presented in the results...82Appendix 6Figures for screening83Appendix 7Braces, casts and traction.85Appendix 8Figures for treatment89Appendix 9Tables for result - screening.91 1.1 Introduction During the clinical affiliation periods in the fourth academic year of the physiotherapy education at Fontys University of Professional Education in Eindhoven, the project group discussed thoroughly what topic to write about for the graduation project. The members of the project group agreed that the spine was a good starting point, due to the high prevalence of back pain in society. The project group chose to write about scoliosis, because the aetiology of scoliosis is not clear for the medical society and this makes it difficult for the physicians to know what treatment intervention to use. During the clinical affiliation periods none of the members of the project group had any clinical experiences from patients with scoliosis. This is due to the fact that the people with scoliosis in Norway are often only given the choice between bracing and surgery. The role of the physiotherapist is very limited, meaning that very few physiotherapists have any knowledge of treatment of scoliosis. The project group wanted to find out more about the different treatment interventions, how they are carried out, and their effects on the curvature of the spine. The project group questioned how screening and treatment is done in different countries and tried to answer these questions. Based on this the project will also focus on the physiotherapists role in relation to active exercises in treatment and prevention of scoliosis. Idiopathic scoliosis is the most prevalent type of scoliose, and within the group of idiopathic scoliosis, adolescent idiopathic scoliosis (AIS) has the highest prevalence (80%). The project group chose to write about AIS, in belief that the most representative literature and research material regarding idiopathic scoliosis would be obtained. The following two main questions were formulated: What interventions are available for detecting adolescent idiopathic scoliosis as early as possible? What is the effect of active exercises and bracing on a patient with adolescent idiopathic scoliosis in relation to preventing progression in degrees of the curve(s)? A descriptive research has been carried out. This type of study is intended to highlight new information to give a better understanding of what exists in nature concerning the subject. The project group would like to help future physiotherapy students by increasing their knowledge about the different alternatives of treatment and prevention of progression of adolescent idiopathic scoliosis. It is also important to increase the quality of physiotherapeutic treatment for patients with adolescent idiopathic scoliosis. The members of the project group have interest in working with patients with adolescent idiopathic scoliosis in the future, and see this as an opportunity to broaden their horizon within this field. The project is divided into two parts: Part 1 Theoretical framework Part 2 Descriptive research The first part of this research report will contain background information about idiopathic scoliosis, screening, and treatment of adolescent idiopathic scoliosis. In chapter 2.1 an introduction to scoliosis will be presented, and in chapter 3.1 the aetiology, symptoms, curve patterns, measurement tools, prognosis, and treatment related to adolescent idiopathic scoliosis are included. Further on there is a thorough explanation of screening of adolescent idiopathic scoliosis (chapter 4.1). In the last chapter in part 1, the theoretical framework of treatment of adolescent idiopathic scoliosis is covered (chapter 5.1). This includes bracing, active exercises, and other less recognised forms of treatment. The information in the outlined topics is based on various articles/literature. The second part explains how the project group carried out the descriptive research. The different information is gathered from critically revised articles, all regarding idiopathic scoliosis. It contains the method (chapter 6.1) used, and the results (chapter 7.1) the project group came up with on screening and treatment of adolescent idiopathic scoliosis. In the discussion (chapter 8.1), the project group have collected the results from the analysed articles and have tried to answer the main questions with this information. Also included here are the project groups interpretations of the results from the articles found. The conclusion (chapter 8.1.4) will carefully consider the different results and an objective view on the subject will be presented. In chapter 9.1 limitations of the project process and recommendations for further research are described. At the end there is a considerable reference list (chapter 10.1) followed by the appendices (chapter 11.1). 2.1 Scoliosis 2.1.1 Introduction Scoliosis is the most deforming orthopedic problem confronting children (1). Hippocrates, in the fifth century BC, was the first to describe this disorder to denote any abnormal curvature of the spine. Galen (AD 131-201) first used the term scoliosis (2). Scoliosis is a musculoskeletal disorder (3). According to the Scoliosis Research Society the definition of scoliosis is a lateral deviation of the normal vertical line of the spine which, when measured by x-ray, is greater than ten degrees (4). It is a potentially progressive condition that affects children during their active growth phase. It mostly subsides upon completion of spinal growth, and this leaves the child with a permanent deformity (1) (fig.1).  Figure 1 (5): Normal and scoliotic spine Its anatomical site in the vertebral column specifies scoliosis. The spine is normally divided into cervical, thoracic, and lumbar spines. Viewed laterally, the physiological curves are lordosis of the cervical and lumbar with kyphosis at the thoracic and sacral segments. The terminology of scoliosis curves implies a curve viewed anteriorly-posteriorly and must be considered pathological (1). Scoliosis is considered to be present in approximately 4% of the population (6), with 2% of the adult population demonstrating some degree of spinal curvature (7). However, different investigations have reported that the percentages of children with scoliosis vary from 2% to 15% of all schoolchildren. This large difference in percentage can be explained by the fact that some examiners record even the slightest asymmetry as a scoliosis, while others include only the curves of 10 degrees or more (8). 2.1.2 Structural and non-structural scoliosis Causes of scoliosis curves can be classified as either non-structural or structural (9). A non-structural or functional scoliosis is a normal spine that appears curved. The curve is temporary, reversible and there is no bone deformity. A non-structural curve will disappear on forward flexion due to not having any structural changes. Correcting the underlying problem, being for example a difference in leg length, a muscle spasm or a postural problem, will treat these curves. A structural scoliosis is an irreversible, fixed curve with bony abnormality or vertebral rotation. The vertebral bodies rotate toward the convexity of the curve, and the spinous processes toward the concavity of the curve. This rotation causes the obvious rib hump-deformity of the back. The structural curves may be progressive and they do not disappear on forward flexion, lateral bending or in the supine position (9). 2.1.2.1 Structural scoliosis The classification of spinal deformity has been standardised by the Scoliosis Research Society, and it is apparent that structural scoliosis accompanies many diseases and abnormalities. According to this list, the following three are the main classifications of structural scoliosis (1): Idiopathic: infantile, juvenile and adolescent. Neuromuscular: neuropathic (due to disease or anomalies of nerve tissue, for example cerebral palsy, spinal cord trauma and lower motor neuron lesion) and myopathic (due to disease or anomalies of the musculature, for example muscular dystrophy). Congenital: this form is due to congenital anomalies of vertebrae or developmental abnormality of the vertebral elements and/or adjacent ribs. This form can be associated with neural tissue defect. In addition types of structural scoliosis are classified from soft-tissue contractures, osteochondrodystrophies, Scheuermanns disease, infections, tumours, rheumatoid diseases, metabolic diseases, neurofibromatosis, connective tissue diseases and traumatic injuries (1). 80% of structural scoliosis is classified as idiopathic, and 20% is classified as structural scoliosis with a known aetiology. These 20% are considered rare but important diseases, which often produce structural scoliosis. The diseases are uncommon, and therefore scoliosis arising from these diseases is also uncommon. The conditions that may cause scoliosis total over 50 different diseases and syndromes; some are exceedingly rare, others not infrequently seen. In these cases scoliosis is often only one of several problems associated with the primary disease (1). 2.1.3 Primary and secondary curves The curvature from structural scoliosis may develop as a single curve (shaped like a C) or as two curves (shaped like a S) (10). The primary or major curve can be considered to be the first of several curves to appear. Often secondary or minor curves develop above or below the primary curve to compensate for the primary deformity in an attempt to maintain normal body alignment (1,11). It is not always easy to decide which of the curves is primary and which is compensatory and secondary. By lateral flexion to left and right is it more obvious to see which curve is the most rigid curve (1) (fig.2).  A. B. Figure 2 (1): Flexibility of the curved spine: A) The thoracic part is structural (primary curve) because side bending to the right side do not change the shape of the curve. B) The lumbar part is corrected by side bending to the left, and is therefore a non-structural curve (compensatory, secondary) (1). 2.1.4 Forms of idiopathic scoliosis Idiopathic scoliosis is the most common diagnosis in structural scoliosis, and 80% of structural scoliosis is classified as idiopathic (1). An idiopathic scoliosis is a lateral curvature of the spine with rotation of unknown aetiology (3). The prevalence of idiopathic scoliosis in patients with a Cobb angle of greater than 10( is in the range of 1.9% to 3% (3). The prevalence of idiopathic scoliosis in patients with a Cobb angle of greater than 20( is 0.3( (3). The spine is normal at birth, but with growth a deformity develops for unknown reasons (12). Uneven shoulders, prominent shoulder blade(s) and ribs (rib hump), uneven waist, elevated hips, and leaning to one side are all signs that should lead to an examination for scoliosis (7). The diagnosis of idiopathic scoliosis is usually made by exclusion of other causes of scoliosis (3). This disorder is divided further according to age, and there are three categories of idiopathic scoliosis (3). The period of infantile idiopathic scoliosis is from birth to the age of three years. The juvenile period is considered from the age of three until the end of the ninth year, and the adolescent period is from the age of ten to the end of skeletal growth (approximately at18 years of age) (13). The adolescent type is the most frequent of the three (4). 2.1.4.1 Infantile idiopathic scoliosis An infantile idiopathic scoliosis is defined as a structural curve appearing with no known cause before the age of three years (13). The incidence of infantile idiopathic scoliosis is very low, and there is a small risk of progression. The infantile form accounts for less than 1% of all cases of idiopathic scoliosis in the United States, and is slightly more common in Europe (4,14). Most curves develop within the first six months of life (14). The majority of the cases (92%) resolve spontaneously, but some progress to severe deformity. This form of scoliosis is more common among boys than among girls, and in 75% of the cases a left convex thoracic curve is seen (4). Girls with a right convex thoracic curve have a poor prognosis. In 1972 Metha developed a method to differentiate between the progressive curves and the spontaneously resolving curves. She found a distinct difference in the relationship of the angle of the rib to the vertebral body, and for this she measured the apical rib-vertebrae angle (RVAD). With an angle of more than 20(, there was a chance of progression. With measurements of less than 20(, the curve is likely to resolve (4,14). Other risk factors for progression includes low birth weight, curve angle over 20(, and rigidity of the curve (4). A child under five years of age with a thoracic idiopathic scoliosis has a higher chance of developing secondary cardiopulmonary problems as compared to an adolescent with idiopathic scoliosis (4). For infants with idiopathic scoliosis, it is likely that the aetiology of the curvature is multifactorial with a genetic tendency to the deformity, which is then triggered off in different individuals by different medical, social or genetic factors (13). No treatment is necessary for the non-progressive curves (14). Observation is indicated for curves with Cobbs angle less than 25( and less than 20( rib-vertebral angle difference (14). The most appropriate treatment with progressive infantile idiopathic scoliosis is EDF-plaster (elongation-derotation-flexion). This plaster is worn for three to four months, and then a new plaster is adjusted. This treatment usually lasts until a significant improvement of the scoliosis is seen, and this treatment can last for three or four years. The earlier the plaster treatment is started, the better the end result (4). There is no doubt that conservative treatment is effective in preventing progression for an infant with idiopathic scoliosis (15). Studies show that the use of the EDF-plaster can make progressive curves resolve (15). In a study by Metha, it is reported that if the curve is totally corrected before the growth spurt, there is no relapse during adolescence (14). There exist few publications concerning the effect of physiotherapy interventions for this group of idiopathic scoliosis. The physiotherapists attention should be on the neuromotorical development, the location of asymmetries, and prevention of further development of asymmetry. In addition, the physiotherapist will give advices to parents concerning caring to allow for a symmetric motorical development (4). 2.1.4.2 Juvenile idiopathic scoliosis Juvenile idiopathic scoliosis is defined as deformity in patients between three and ten years of age (14). Approximately 12% to 21% of the cases of idiopathic scoliosis are juvenile idiopathic scoliosis (4,14). The juvenile form is more common in girls, and the female-to-male ratio is reported to be of 2:1 to 4:1 (14). The majority of the curves are right thoracic (62%), followed by the double thoracic curve (22%), the thoracolumbar curve (15%) and the lumbar curve (1%) (4). Juvenile curves can progress and cause severe deformity and impair pulmonary function causing increased mortality (14). 70% of the children with juvenile idiopathic scoliosis experience progression and need treatment (4,14). 50% of these will in turn need an operation. Having a kyphosis of 20( or less, and a curve of 45( or more are risk factors for progression of this type of scoliosis (4). In general, juvenile idiopathic scoliosis does not resolve spontaneously as in contrast to infantile curves (14). There is a high incidence of intraspinal pathology related to juvenile idiopathic scoliosis, and special attention for this is important (4). Theories regarding the cause of adolescent idiopathic scoliosis may also be applicable to juvenile idiopathic scoliosis (14). The juvenile form of idiopathic scoliosis is unique in that it tends to progress during a relatively quiescent time of spinal growth (14). The most appropriate treatment form for juvenile idiopathic scoliosis is bracing (4). Bracing is applied for curves over 25( and for those with a risk of having progressive curves. The physiotherapy interventions for this type of idiopathic scoliosis are more or less the same as for the adolescent form (4). 2.1.4.3 Adolescent idiopathic scoliosis This form of idiopathic scoliosis will be described more extensively in chapter 3.1, and the reader is referred to this chapter for further information concerning the subject adolescent idiopathic scoliosis. 3.1 Adolescent idiopathic scoliosis 3.1.1 Introduction Adolescent idiopathic scoliosis (AIS) is a condition characterised by a lateral curvature of the spine that appears during adolescence with no known cause (4). Affected individuals are otherwise normal with no neurological or physical abnormalities (16). Adolescent idiopathic scoliosis is the most common form of idiopathic scoliosis (11). It represents about 80% of this type of scoliosis (16). 90% of the cases are female, and 90% of the cases have a convex right curve. 50% develop curves greater than 70( (11). The prevalence of idiopathic scoliosis in the general population is measured on adolescents of 16 years of age (4) (table 1). If the age 16 is used as the end point, 2% to 3% of the population at age 16 will have scoliosis measuring 10 degrees (Cobb angle) or greater (4). There is an overall female prevalence for adolescent idiopathic scoliosis of 3,6:1 (4). With increasing curve severity there is an increasing female predominance (4) (table 1). Table 1. Prevalence of adolescent idiopathic scoliosis (4). Angle of CobbFemale : Male PrevalencePrevalence (%)( 10(1,4 2 : 12 -3( 20(5,4 : 10,3 0,5( 30(10 : 10,1 0,3( 40(( 0,1 Adolescent girls with progressive adolescent idiopathic scoliosis have a morphological somatotype that is different from the normal adolescent population. Girls with progressive adolescent idiopathic scoliosis are significantly less mesomorphic than control girls. Patients with progressive adolescent idiopathic scoliosis appear to have a deficit in the development of their bony structure and/or muscular tissue. This explains why the patient has an ectomorphic or an endomorphic appearance. This can be of value as a predictive factor for early identification of subjects with adolescent idiopathic scoliosis at greater risk of progression. Men are in general more mesomorphic than women, and this may in part explain the common observation that more adolescent girls have progressive adolescent idiopathic scoliosis than boys (17). Adolescent idiopathic scoliosis is not detrimental to organic health. Branthwaite confirmed this fact in 1986 (15). The reasons for treating late onset idiopathic scoliosis have to do with appearance and deformity with all its social and psychological deprivation, and not with prevention of organic health problems (15). Because the adolescent idiopathic scoliosis is mostly a matter of appearance and deformity, how it affects the patient is absolutely crucial to the choice of treatment (15). It is important to know if the deformity is acceptable or not. This is very individual, and if the deformity is acceptable the main aim of the treatment is to maintain acceptability. For these cases, non-operative treatment would have an important role (15). The conservative treatments for the patient with an adolescent idiopathic scoliosis can be divided into three main categories; exercise therapy, bracing, and electrical stimulation (4). Through the years different exercise programs have developed. The most famous ones are the method of Schroth and the side-shift therapy (4). See chapter 5.1 and result (chapter 7.1) for further information about the method of Schroth and the side shift therapy. The information presented below concerning aetiology, curve patterns, symptoms, complications, measurement tools, and progression is in general applicable for all the three types of idiopathic scoliosis. Due to this the term idiopathic scoliosis will be used in the text. 3.1.2 Aetiology Intensive research is being carried out throughout the world concerning the aetiology of idiopathic scoliosis (1). In idiopathic scoliosis, among patients from six years of age to the end of growth, there is evidence for strong genetic factors. Some evidence also shows an inherited tendency to the deformity in patients under this age (1,13). Already in 1934, in a study by Garland, reports of inheritance of idiopathic scoliosis were presented (13). After this, several studies have reported high familial concentration of idiopathic scoliosis (1,2,13,18). A recent meta-analysis showed that not only is the risk for scoliosis greater in monozygotic twins than in dizygotic twins, the rate of curve progression is nearly identical among twins subjected to a variety of environmental influences (19). Women with a curve greater than 15( have a 27% prevalence of idiopathic scoliosis among their daughters (20). 11% of first-degree relatives are affected, as are 2.4% and 1.4% of second and third degree relatives respectively. This makes genetics a possible cause for this disease (18,20). Some studies have found abnormalities of melatonin (sleep and growth-hormone), platelet calmodulin (protein), and collagen (structural protein) associated with idiopathic scoliosis. These biological factors may contribute to the development of idiopathic scoliosis (21). Other studies report that the role of melatonin and calmodulin in the development of idiopathic scoliosis is likely secondary, with indirect effects on growth mechanisms (18). Hormonal disturbances can be a factor related to the cause of idiopathic scoliosis (22). Girls with adolescent idiopathic scoliosis grow faster and have an increased growth before menarche compared to girls without adolescent idiopathic scoliosis (7,22). Girls with adolescent idiopathic scoliosis also have earlier puberty than their peers (7), and they are taller than their normal contemporaries (13,18). A higher level of growth hormones and testosterone is found in girls with adolescent idiopathic scoliosis (22). This could suggest a hormonal influence, but there exists no clear explanations for this (7,22). Neurological dysfunctions on different levels, and growth disturbances of vertebrae and ribs have been suggested as a cause of adolescent idiopathic scoliosis (18,22). Abnormal processing in the brain and inherited imbalances in perception or coordination is linked to the development of idiopathic scoliosis (21). A study found that nutritional defects should be considered as a possible cause of idiopathic scoliosis (22). In a historical view, idiopathic scoliosis has been attributed to a wide variety of conditions ranging from poor posture to poor nutrition. Recent search for the cause of idiopathic scoliosis has emphasised the structural elements of the spine, spinal musculature, collagenous structures, endocrine system, central nervous system, and genetics. None of the studies have shown convincing evidence of the cause, and it seems difficult to determine what is the cause and what is the effect of idiopathic scoliosis (2,18,23). The aetiology of idiopathic scoliosis remains unknown, but it appears to be multifactorial (1,18). Because of this, diagnosis of scoliosis remains a clinical one, and treatment remains aimed at prevention or correction of already existing curves (1). With time, continued research will hopefully lead to the identification of the various factors involved in the causation of this disorder. Early identification may lead to earlier treatment (18). Curve patterns and location Curve patterns are stereotype patterns of the spine, and are named according to the location on the spine (4). Finding the apex of the curve identifies the location of the curve. This is the vertebra within the curve that is the most off-center (1). There exist two systems for classifying curve patterns. According to one of these systems, there are in general four different curve patterns in idiopathic scoliosis (1) (fig.3). For all patterns of idiopathic scoliosis, the most common age for it is in the early teens (13). 1. Lumbar idiopathic curve: A lumbar idiopathic scoliosis has its structural curve in the lumbar region. Most commonly the apical vertebra is the first or second lumbar. There will always be a compensatory curve above and below the structural curve. Girls are affected more than boys. In 80% the curve is left convex (11). This pattern of scoliosis is rare. There are no ribs protruding, only one hip, which makes detection of these curves more difficult (11). An important late consequence for lumbar scoliosis is backache. Mostly a corset suffices to relieve pain (13). 2. Thoracolumbar idiopathic curve: A less common pattern of idiopathic scoliosis, a thoracolumbar curve, is a curve with its apex at or near the thoracolumbar junction (13). These curves are in 80% of the cases right convex (4). 3. Double structural idiopathic curve: A double structural idiopathic scoliosis implies two structural curves present. One curve is in the thoracic part, and one is in the lumbar or thoracolumbar part. In 90% of the cases there is a right convex thoracic and a left convex lumbar curve (4). This pattern appears at all ages, and it is a common pattern. Usually there are compensatory curves above and below the primary curves. It is therefore usual to see four curves instead of three as in the single structural curve form. Due to the fact that each curve balances the other, the deformity is not very marked (13). 4. Thoracic idiopathic curve: In the adolescent, the thoracic idiopathic scoliosis is the most common of all patterns. A thoracic curve has its apex in the thoracic area of the spine (between T2 and T12). 90% of the patients are female, and 90% has a right convex curve (11). The young girl with her right-sided thoracic curve is the best-known form of scoliosis (13). In the adolescent with an onset of thoracic scoliosis, 25% will have curves exceeding 100( and only one of three will finish their growth with curves of less than 70(. Many require treatment and surgery, and the earlier treatment the better (13).  Figure 3 (9): Examples of scoliosis curve patterns Another classification of curve patterns is according to King (3,4) (table 2). This system classifies five different curve patterns related to the location and type of the curve (3,4). Table 2. Classification of curve patterns according to King (3,4): TypeCriteriaType I True double major curve (S-curve) where both the thoracic and the lumbar curve cross the midline. Both curves are structural. The lumbar curve is bigger than the thoracic on x-ray in standing position. The thoracic curve is the most flexible curve on side flexion. Type IIFalse double major curve (S-curve) where both the thoracic and the lumbar curve cross the midline. Thoracic curve is larger than lumbar curve. The thoracic curve is the primary curve, and the lumbar curve is a secondary curve. Type IIISingle thoracic primary curve where the lumbar curve does not cross the midline. Type IVA long thoracic or thoracolumbar C-curve where L5 is centred above sacrum, but L4 is a part of the long thoracic curve. Type VDouble thoracic curve where Th1 is to the convexity of the cranial curve, and the cranial curve is structural by side flexion.  Symptoms and complications There are usually no symptoms in early idiopathic scoliosis. Three complications of idiopathic scoliosis justifies the need for early recognition and treatment: cosmesis, pain, and cardiopulmonary function (1). Cosmesis: The most usual reason for seeking medical evaluation is abnormal appearance due to the presence of idiopathic scoliosis. Due to this fact, it is unfortunate that it is present much more in girls compared with boys (1). Pain: Back pain is more common among patients with idiopathic scoliosis compared to the general population. The prevalence of back pain is higher with lumbar curves (4). However, pain attributable to scoliosis is usually not prevalent or severe (1). A marked lumbar scoliosis may cause pain in the lower back (1). Because the onset of scoliosis is gradual and almost always painless, a significant curvature can develop without knowing it. This entails the impotency of early detection (7). If a patient with idiopathic scoliosis has back pain, a careful history and physical examination should be performed. If this reveals normal findings, a diagnosis of idiopathic scoliosis can be made. In this way the idiopathic scoliosis can be treated appropriately, and non-operative treatment can be initiated for the back pain. It will not be necessary to evaluate every patient who has scoliosis and back pain (24). Cardiopulmonary function: Most cases of idiopathic scoliosis never reach severe magnitude, but those that do can have significant sequela (25). Patients with a moderate to severe scoliosis and major thoracic deformity have the possibility of cardiopulmonary complications. This is one reason given for treating scoliosis. A relationship exists between the degree and the region of the scoliosis and the impaired pulmonary function. Curves in the thoracic area that approach and exceed 50( are risk factors for decreased pulmonary function (1). However, significant changes of pulmonary function are not common until the thoracic curve reaches a level greater than 70(. In addition, the changes are often seen late in life in untreated patients with infantile or juvenile idiopathic scoliosis, and are then a threat to life. Decreased pulmonary function is unusual to see in adolescent idiopathic scoliosis (16). There can be a reduction of vital capacity, total lung capacity, and expiratory peak flow rate. The vital capacity is related inversely to the degree of increasing curvature, but also to the rotational deformity of the vertebrae involved in the curve (1). Patients with severe scoliosis may develop a dyspnea with a breathing pattern of frequent, rapid breaths with a small volume of air being moved during a specific period of time. Breathing may also become strenuous to the patient because the rib cage in addition to being deformed also is relatively immobile. Pulmonary hypertension can result, leading to cardiac decompensation. Treatment of scoliosis, either operative or non-operative, gives no significant change in total lung capacity or vital capacity. This failure to improve respiration in curves of 60( or more makes it even more important to have early diagnosis and treatment of minimal curves before irreversible respiratory problems occur. The rotational deformity causes greater respiratory difficulty than the lateral curving. Early recognition and treatment with frequent follow-up is important to assess the progression of the development of the curve (1). Early onset idiopathic scoliosis (before 5 years of age), is most at risk for development of restrictive pulmonary disease, pulmonary artery hypertension, and cor pulmonare (14). There are conducted different studies concerning the long-term effect of the untreated scoliosis patients. Results show increased mortality rate, increased risk of cor pulmonale, and right ventricular failure with high thoracic curves over 100( (4). Other complications: Idiopathic scoliosis is a multifactorial disease that can affect several systems of the body (6). The unleveling of the head and eyes in a scoliotic patient affects the balance mechanism, proprioception, and oculo-vestibular function of the patient (6). Idiopathic scoliosis alters balance control (26). Static balance control is more affected in patients with low major curves in relation to a higher lateral disequilibria (26). Dynamic balance control is more affected in patients with high major curves. Because of lack of length to compensate above the major curve, a reduced horizontal repositioning of the skull induces vestibular asymmetry (26). Patients with double major curves appear to compensate better and show fewer posture control abnormalities (26). Due to the lateral deviation, the dorsal nerves can be stretched or atrophied, and this may affect the nerves ability to transmit impulses. The vertebral bodies are subjected to abnormal pressure due to the distortion, and this may result in vertebral asymmetry (6). The hyper flexibility in the ligaments that hold the spine contributes to a distortion that negatively impacts the discs. Due to the changes in the force vectors caused by the curvature, the muscles can start working against the body. Some patients with idiopathic scoliosis have digestion and absorption problems in addition to a compromised immune system. The nutritional imbalances may lead to hormonal imbalances that can contribute to ligament laxity and acceleration of the disease (6). Persons with idiopathic scoliosis have a higher risk of loss of bone density (osteopenia) and osteoporosis (10). A study of Cheng and Guo showed that 68% of scoliotic individuals had a significantly reduced bone mineral density. The decreased bone mineral density did not correlate with the scoliosis degree or pattern. The findings from this study suggest that osteopenia in idiopathic scoliosis may be related to the primary aetiology of the disease rather than secondary to the mechanical forces associated with the back deformities (27). Complications of having a scoliosis can be emotional problems or lowered self-esteem as a result of the condition or its treatment (28). In addition, increased fatigability, cosmetic deformity, psychogenic problems with body image, increased unemployment, decreased likelihood of marriage, and other socio-economic problems may further complicate the situation (25). The psychosocial effects of scoliosis are described by different authors, and the conclusion is that the cosmetic deformity is more accepted by the older patients compared to the adolescents (4). Measurement tools Curves are universally measured by the Cobb method (1,3). A parallel line is drawn along the superior endplate of the upper end vertebra and along the inferior endplate of the lower end vertebra. The upper end vertebra is defined as the upper vertebra that is tilted maximally into the curve, and the lower end vertebra as the lower vertebra that is tilted maximally below the curve (3). Right angles are then dropped from these lines, and the intervening angle (Cobb angle) is a measurement of the degree of the scoliotic curve (3). When measuring double curves, a transitional vertebra between the upper end vertebra of the upper curve and the lower end vertebra of the lower curve exists. The inferior endplate of the transitional vertebra represents the inferior aspect of the upper curve and the superior endplate of the transitional vertebra represents the upper end of the lower curve (3) (fig.4). Figure 4 (3): Measurement of Cobbs angle Rotation is an inherited structural change in scoliosis (1). The apical vertebra refers to the most rotated vertebra in the curve. This rotation creates the greatest cosmetic defect, and in the thoracic area, cardiopulmonary involvement results as the greatest potential functional impairment (1). The vertebrae are always rotated around the vertical axis. The vertebrae bodies point to the convexity and the spinous processes to the concavity of the curve (11). The rotation occurs posteriorly on the convex side of the scoliosis and anteriorly on the concave side of the scoliosis (1). The ribs on the convex side are also rotated around posteriorly and stand out as a prominent hump. The ribs on the concave side are pushed together anteriorly (11). There are no universally accepted methods for measuring rotation (1). The rotation can be recorded in amount of displacement of the pedicles in relation to the midline. From 0 to 4 the amount of rotation toward the concave side is measured from pedicle slightly toward midline to pedicle moving beyond midline (1). Progression It is difficult to give an exact definition of progression of idiopathic scoliosis, but there appears to be different prognostic factors related indicating progression (4). In most studies, progression of a curve less than 20 degrees is defined as an increase of 5 degrees or more as measured by the Cobb method over two or more visits. If the curve is between 20 and 30 degrees, an increase of 3 degrees or more over two or more visits is defined as progression. If the curve is 30 degrees or more, any increase in degrees of the curve is considered to be progression. It is unknown whether this progression will continue, and what the final curve will be (5). The natural history of adolescent idiopathic scoliosis is relatively benign and only a small minority progress to unacceptability (15). Progression of a curve is in general related to size of the curve, area of the spine involved, patient gender, and the physiological age of the child. Larger curves progress more than small curves. Thoracic and double primary curves progress more than single lumbar or thoracolumbar curves (20). The higher the structural curve is in the vertebral column, the worse the prognosis (13). The thoracic curve with its dropped shoulder, prominent iliac crest, and large rib rotation is the most ugly curve, and it has also the worst prognosis for expected severity in degrees of the curvature (13). Girls with a lumbar curve have half the chance of progression compared to those with a thoracic curve. Boys have a risk for progression of only 10% of that of girls (4). Progression depends also on the amount of growth remaining until skeletal maturity (3,16). An early onset of idiopathic scoliosis with many years of growth ahead, means that the prognosis is worse than if the curve begins late in childhood (13). The Risser sign (0-5) is used as a measurement of skeletal maturity (11) (fig.5).  Figure 5 (3): The Risser sign: The iliac apophysis matures by starting to ossify at the anterolateral portion of the iliac crest and then progressively moves posteromedially. An x-ray of the pelvis shows when the iliac apophysis has ossified and fused (11). Grade 0 indicates no ossification, grade 1 signifies up to 25% ossification, grade 3 signifies 26% to 50% ossification, grade 3 signifies 51% to 75% ossification, grade 4 signifies 76% up to 100% ossification, and grade 5 signifies complete bony fusion of the apophysis (29). After skeletal maturity progression of the curve is minimal. In an immature child (Risser sign 0-1) with a small curve (under 19(), the chance of progression is 22%. If the curve for the same child is 20-29(, the risk for progression increases to 68% (29). A child with Risser sign 2-4 with a small curve (under 19() will have a 1.6% risk of progression. If the curve for the same child is between 20-29(, they have a 20% risk of progression (20). Early recognition and treatment is important in preventing progression (1). Progression is mostly seen during the growth spurt (4) (fig.6). Also gravity will continuously force the curve to be more lateral (8). The pressure on the concave side constantly increases, and the pressure constantly decreases on the convex side. This may lead to a wedged shape of the vertebrae (8). The trunk musculature has the same effect as gravity, and is further reinforcing the process. With an increasing curve, the thorax becomes increasingly more deformed (8).  Figure 6 (4): Development of scoliosis compared to speed of growth. The period of highest risk related to curve progression in adolescent idiopathic scoliosis is around puberty. This is when the growth rate is the fastest. _______: angulation of curve (degree). -----------: growth velocity of upper segment (cm./year). 4.1 Screening of adolescent idiopathic scoliosis 4.1.1 Introduction Screening has been defined as the presumptive identification of an unrecognised disease or defect by the application of tests, examination, or other procedures which can be applied rapidly to differentiate between those who may have a particular disease from those who do not (30). Screening can also be viewed as a form of secondary prevention that attempts to identify the abnormalities when symptoms are present, but at a much earlier stage before the symptoms become obvious. It also implies that a firm diagnosis will be made and treatment will be more effective (30). Screening tests hope to sort out the healthy persons who do not have the disease from those who probably have the disease. It is important to mention that screening tests are not intended to be diagnostic (30). If an adolescent person has suspicious findings, referral to their physician for diagnosing and treatment has to be made (31). Screening programs for scoliosis began in the 1940s in the USA (21). These screening programmes are now mandatory in middle or high schools in many states in the USA and in other countries (21). Since then the screening program has not been able to escape the controversy about its value. The total amount of teenagers with severe spinal curves has decreased, but large curves originating from adolescent idiopathic scoliosis still occur today. Some of the blame has to go to the primary physicians failure to examine the childs back during puberty. Many adolescent people have limited financial possibilities and therefore infrequently see their physician. These are two good arguments for school screening for scoliosis (32). 4.1.2 Reason for screening The importance of early diagnosis of structural scoliosis in children and teenagers is generally accepted (33). The main purpose of school screening is to control the curve progression by conservative measures and thereby reduce the number of young patients requiring corrective surgery. It is important to have good guidelines to be able to promote an effective school-screening program. The following points should be representative to such a screening program: - The test should be sensitive enough to detect minor curvature without too many false-positives results. - It should be easy to carry out, promoting minimal personnel error factor, and be able to document the observed trunk asymmetries and record even small changes in the deformity. - It should be non-invasive and reduce the number of roentgenograms, and it should be cost effectively justifiable (33). The most common test for detecting scoliosis is the Adams forward bend test. This test needs experienced personnel to be able to decrease the amount of false-positive findings. The large disadvantage is that x-rays are necessary to record the degree of scoliosis and to evaluate the progress at examinations. Without the x-ray it is too difficult to see any progression from year to year. Several attempts have been made to combine the Adams forward bend test with other measurement tools to make it more reliable (33). Screening is most typically performed at the ages between 11 and 14 years. Some of the most known health organisations related to scoliosis are recommending approximately the same age group, but there are some differences between their opinions of frequency of control. The Scoliosis Research Society (SRS) recommends annual scoliosis screening of the children from 10 through out 14 years of age (32). The American Academy of Orthopaedic Surgeons recommends scoliosis screening of girls at ages 11 and 13 years, with screening of boys once at the ages of 13 to 14 years (32). American Academy of Paediatrics has recommended screening during routine clinic visits every other year from 10 until 16 years of age (32). 4.1.3 Arguments for and against screening Experts on the scoliosis subject disagree on the value of screening. The US Preventive Task Force has tried to sum up the different opinions on screening (21). This list of advantages and disadvantages are developed by experts in the US Preventive Task Force, and confirms the content on pro and con for all the articles on screening used in this project. Arguments against screening according to experts in The US Preventive Task Force (21): Screening procedures are very dependent on the skill of the examiner, and the screening tests are not accurate enough. Schools often refer children with minor curves who are not at any risk for a progressive or serious condition to physicians, and such over-referral add considerably to the cost of the health system. In one major study in 1999, 94% of the children referred to a physician by the school did not require treatment. (Over 2000 children were screened in order to find only 5 children who did need treatment.) At the time of the Task Force, studies were also showing no benefits from the early treatments, specifically braces. Experts against screening argue, that such programs either will not prevent curve progression and surgery, or are unnecessary in the first place since curvatures often do not progress at all. Arguments for screening according to other experts (21): Universal screening is useful for producing information on scoliosis that may eventually lead to knowledge of its cause and ways to prevent it. Bracing has been proven to be effective since the Task Forces recommendation of the fact that early treatment can be important. Without screening, the chances are small that children with scoliosis will be diagnosed at an early stage if they can only rely on examinations by a family physician or paediatrician. Such physicians often do not even look at backs and, if they do, they tend to use only the Adams forward bend test, which is not accurate. Finally, wide-spread screening would be cost effective if schools had reasonable guidelines to use for determining which children should see a physician for further testing. Some experts suggest the following guidelines for determining the need for a physician referral (21): Children should be sent to a physician only if they have a 30-degree curve. (A 20-degree curve with a 5-degree trunk rotation has been the criteria for recommending treatment, although up to 80% of 20-degrees curves do not get worse.) Children with curves between 20 and 30 degrees should be screened every six months. Such guidelines would detect about 95% of all genuinely serious cases while referring only 3% of all children tested, thereby cutting costs without jeopardising children. Some of the most important issues against school screening are; cost effectiveness and the large amount of false-positives diagnosed. Other physicians and patients argue that there is no cost too great if it can prevent a child from having spinal fusion. 4.1.4 Screening staff In most screening test programs the school staff, aided by outside individuals, play a very important part in the organisation of the screening program. Nurses and physical educated teachers are the backbone of the system. Lonstein states the importance of screening staff attending yearly workshops in the initial years of a screening program. These workshops should function as a refresher course for established screeners, and as an instruction for new screeners (5). 4.1.5 Screening methods The screening method used most widely is the Adams forward bend test (33). This is the most cost-effective way of screening, but also scoliometer, topography, and radiography are being used (33). Adams forward bend test: The Adams forward bend test is performed when the child is bending forward with dangling arms, feet together and straight knees (34) (appendix 6, figure1). The curve of a possible scoliosis will be more apparent when the child is bending over. The features of the scoliosis will show an imbalanced rib cage with the one side being higher than the other. The Adams forward bend test has a poor sensitivity for abnormalities in the lower back (34). When taking the validity of the Adams forward bend test into consideration, it can be measured by three parameters: The sensitivity is the ability to select those people that have the disease, the specificity should recognise those who do not have the disease, and the predictive value must have a positive finding when it actually signifies the disease (31). Several reports have estimated the effectiveness of the Adams forward bending test in the clinical setting (31). The Adams forward bend test has been found to be sensitive. Goldberg et al. states that even the slightest asymmetry can be detected with the naked eye (31). On the other hand Grossman questions the abilities of the examiner to detect asymmetry by visual observation alone. Howel et al. tested the examiners, who were nurses and physiotherapists, on their skills of detecting asymmetry. 26% of the trained nurses and 13% of the physiotherapists failed to detect asymmetries in patients who had at least 10 degrees curve (31). The predictive value is very important, the yield will depend a great deal on the prevalence in the population. High prevalence is important for the validity of the screening test, the less prevalent the disease is in the population, the more false-positives will be found (36). Scoliometer: Bunnel developed the scoliometer in 1984 (33). The scoliometer is widely used as an instrument to improve the Adams forward bend test (33). The idea of the scoliometer was that it should be used on patients identified as suspicious on the Adams forward bend test (37). The scoliometer is a fluid filled inclinometer with an enclosed floating ball that shows the angle of trunk rotation on a scale from 1-degree increments that ranges from 0-30 degrees (5). The scoliometer is placed on the back of the patient and is used to measure the highest point of the curve (appendix 6, figure 2). It is important that the patient continues bending so that the examiner more easily can see the curve of the lower back, and measure it. The forward bend test in combination with the scoliometer is performed twice, with the patient returning to standing in between (33). The scoliometer is very specific to rib cage distortion; it measures positive in more than half of the children who turn out to have very little or no deformity (33). Even though the scoliometer is specific it is not accurate enough to guide treatment (33). The Adams test alone has put school screening in a questionable light, mostly because of its large amount of false-positive cases (37). Some of the included research articles are discussing the possibility to combine the Adams forward bend test and the scoliometer to make the screening more reliable. Moir Topography: Moir Topography is a three dimensional technique for describing the shape of a body (33) (appendix 6, figure 3 and 4). The contour lines are developed by interference between the lines of the grating and their shadows casted on the surface of the body behind the grating (33). The intervals between the grid lines project well-defined shadow lines on the body comparable with the contour lines on a topographical map (33). Moir topography describes mainly the rotational component of a structural scoliosis and not so much the lateral deviation (33). It is reported in the literature that Moir topography gives a high number of false-positives results in addition to high cost. Moir topography has the highest false-positive result of the four screening interventions (30). Radiography: The child can be sent to a specialist who takes x-rays if the screening is positive. Such positive findings should be monitored every 4 to 6 months using x-ray. X-ray is the most accurate measurement tool compared to Adams forward bend test, scoliometer and Moir topography (34). By x-rays it is possible to calculate by Cobbs method the severity of the scoliosis. The picture will also reveal other abnormalities such as kyphosis and hyperlordosis (34). Scoliosis radiography is ideally done in a standing posterioanterior and lateral position of the spine, and the picture is taken from the lower cervical to sacrum at the level of pelvis (32). According to WebMD Health it is important for the radiography technicians to protect the child as much as possible from the radiation. It has been reported increased risk for cancer in people with scoliosis because of exposure to x-ray radiation (34). 4.1.6 Referral To prevent many false-positive referrals, the children with positive findings are re-checked separately on another day. If the re-check is positive, the child will be referred to a paediatrician or family physician. The physician will retest to confirm the physical finding. If the physician agrees with the finding the child is sent to standing radiography. If the radiographic picture confirms scoliosis, the child is referred further to an orthopaedic surgeon (5). The orthopaedic surgeon will conduct an investigation consisting of six different parts: General examination, examination of deformity, imaging assessment, curve measurement, rotation assessment, and skeletal maturity (38). A proper diagnosis is very important, because misjudgement can lead to unnecessary x-rays and stressful treatment in children who are not in danger of a curve progression (33). 5.1 Treatment of adolescent idiopathic scoliosis 5.1.1 Introduction Scoliosis is more easily to prevent than to correct if the term prevention is used to mean the control of deterioration (13). The key to the treatment of idiopathic scoliosis is prognosis, and the aim is to prevent the curve becoming severe (11). Treatment consists mainly of early recognition, correction of existing curves, and prevention of further progression of the curves (1). The best treatment for each patient is based on the age, remaining growth, degree and pattern of the curve, and the type of scoliosis (3). Less than 10% of positively screened children aged 10 to 16 years (curve(10() will require active treatment (39). 85% to 90% of these may be successfully treated with non-operative means (39). Treatment options are exercises, bracing, and surgery. Studies of treatments like chiropractic manipulation, electrical stimulation, nutritional supplementation, and exercises have not shown to prevent curve progression (3). However, exercises are encouraged in patients with scoliosis to minimize any potential decrease in functional ability over time and to maintain overall fitness (3,21). Exercises can improve posture, increase flexibility, and improve general tone in muscles and ligaments (1). Exercises may also have a psychological value by improving well being and self-esteem (1). A study from Germany showed, that patients with an average curvature of 27( had less progression of the curve after physiotherapy compared to what was expected in patients with no treatment (21). Moderate exercise is not harmful and is extremely important for maintaining healthy supportive muscles and preventing disk degeneration (21). At present, exercise treatment is still considered very important, but only as supportive therapy (27). Curves of less than 10( are not considered to present scoliosis. They are extremely unlikely to progress, and generally do not need treatment (10). If the child with a curve of less than 10( is young and physically immature, the progression can be followed by regular check-ups (10). Observation treatment is done with evaluation every four to six months on curves that are between 20 and 30( (16). The treatment option for progressing curves, or curves over 30( in a skeletally immature patient, is generally bracing (10,16). The goal of bracing is to stop the progression of the curve (10,16). If it is impossible to control the curve by orthotic means, surgery is indicated (16). Surgery is recommended if the curve is greater than 40( and continuing to progress, or if the curve is greater than 50( (10). Surgery is also recommended for mature adolescents with large curves that are likely to progress in adulthood (10). The primary goal for surgery is to prevent spine deformity progression, and the secondary goal is to diminish spinal deformity (16). The limitations imposed by the treatments are often very difficult to handle, and this may threaten the self-image for teenagers (28). It is important with emotional support for adjustment to the limitations of treatment. Professionals involved in this treatment should be helpful in explaining the treatment (28). For the success of any treatment, compliance is essential. A team approach, with several health professionals involved, is beneficial and often necessary to support the patient through the treatment process (21). Health professionals involved can be an orthopedic surgeon, an orthotist, a physiotherapist, and a nurse (21). In the following text different treatment forms of adolescent idiopathic scoliosis will be covered with an emphasize on bracing and active exercises. 5.1.2 The different treatment interventions Bracing Bracing is a common used treatment form for adolescent idiopathic scoliosis (1,13). It is covered extensively in this project. There are many different forms of braces used as treatment for adolescent idiopathic scoliosis. Active exercises Active exercises according to Schroth, Becker, Klapp, Blount and the side-shift therapy are some of the exercises used as treatment for idiopathic scoliosis. Active exercises are often used in combination with bracing (40,41,42). Exercises are often popular alternatives for the patient when bracing is not an option due to decreased compliance. Casting Casting is an alternative to bracing, but since a cast has to be worn 24 hours a day there will be trouble with the hygiene. A brace is therefore mostly preferred (1,13). (Appendix 7 for further information about casts.) Traction Traction is often used for great scoliotic curves (>90) were the side pressure system of the brace fails (1,13). (Appendix 7 for further information about traction.) Surgery If non-operative treatment of adolescent idiopathic scoliosis fails there is always the possibility to perform surgery, although this is usually the last solution considered. Usually patients with scoliosis fall into one of two categories if surgery is indicated. These categories are classified according to the age group (50). Indications for surgery in the younger scoliosis patient (up to 40 years) include (50): Thoracic curves greater than 50 to 60 with chronic pain that is unrelieved by conservative management. Significant deformity that is unacceptable to the patient. Indications for surgery in patients over 50 years include (50): Documented curve progression with coronal or sagital plane imbalance. Back or radicular pain or symptoms of spinal stenosis associated with lumbar curvatures. Significant loss of pulmonary function not attributable to underlying pulmonary disease. Absolute contraindications for surgery (50): 1. Previous and present chest wall or pulmonary pathology. 2. Patients with a history of previous thoracotomy, emphysema, and pleurodesis on the ipsilateral side run a significant higher risk of lung injury and should be excluded from surgery. Relative contraindications (50): 1. Severe COPD 2. Patients under five years of age. 3. Risser sign below 4. A combination of transpedicular fixation in the lumbar spine with segmental hooks and sublaminar wires to achieve fixation in the thoracic spine can be used. There are different forms of operations that can be performed, but information concerning surgery will not be covered further in this project since the focus is on non-operative treatment forms for adolescent idiopathic scoliosis (50). 5.1.2.1 Bracing The purpose of bracing is to keep the curve from progressing as a child grows (1). Short history of orthotic treatment Orthotic management of spinal disorders dates back at least to the Middle Ages. Some of the concepts underlying those primitive devices, for example the three point forces, remain valid today. Spinal bracing utilizes these primary objectives. Bracing controls back pain by limiting motion and unloading discs, vertebrae, and other spinal structures by compressing the abdomen. It stabilises weak or injured structures by immobilizing the spine. The three-point force systems provide correction or prevent progression of a deformity (45). The segment of the body that is being controlled generally classifies spinal bracing terminology: Sacroiliac (SIO), lumbosacral (LSO), thoracolumbosacral (TLSO), cervicothoracolumbosacral (CTLSO), cervical (CO), and cervicothoracic (CTO) orthoses. Control is described in terms of spinal flexion, extension, rotation, and lateral bending (41). Over the centuries physicians have used a wide, and sometimes strange, variety of devices to straighten a crooked spine (45). Galen first used the words scoliosis, lordosis, and kyphosis. With dynamic bracing and an exercise program he treated spinal deformity. Pare wrote extensively on the use of spinal supports and braces. Throughout the nineteenth century the Europeans developed a vast amount of devices fashioned from steel, leather, and plaster, designed to correct the deformities of the spine. The modern era of orthotic treatment for spinal deformities began with the development of the Milwaukee brace (cervico-thoraco-lumbo-sacral orthosis) by Blount and Schmidt in Milwaukee, Wisconsin in 1945 (46). Types of braces - The Milwaukee brace The Milwaukee brace underwent design changes over the years, reaching its present form around 1975 (appendix 8, figure 3). It is still used today, particularly for high thoracic curves (45). Many of other orthoses (TLSO), adjusted with different modifications, have then derived from the Milwaukee brace, built on the same reasoning; the three point pressure system (1,13,51). (Appendix 7 for further information about the Milwaukee brace.) TLSO braces There are many TLSO (thoracic-lumbar-sacral orthosis) systems available today. They are often also referred to as underarm brace or low-profile braces (45). Some of them include: Boston, Miami, Rosenberger, Lyonnaise, Wilmington, and Charleston orthosis (3). They are made of modern plastic materials and are contoured to conform to the patients body. While they all differ somewhat in construction, they work on basically the same principle (45). The TLSO braces eliminate the cervical component of the Milwaukee brace, and are more often prescribed for cosmetic reasons (46). With help from biomechanical engineers, orthopaedists, and orthotists, a better understanding of the biomechanical function (mechanisms of action) of spinal orthosis has been gained. This resulted in the design and improvement of newer, shorter orthoses such as the TLSO, which were used to treat curves lower in the spine. Although the shorter profile brace (TLSO) is standard for present day treatment of scoliosis because of the ability to completely conceal the brace with clothing, the Milwaukee brace is still the only orthosis that is best to treat curves higher in the spine (apex T-8 and up) and for the treatment of kyphosis which usually is in the mid and upper thoracic spine (46). (Appendix 7 for further information about two common TLSO braces.) External correction-devices External devices advocated in the treatment of scoliosis are numerous and many have therapeutic value. These appliances include various forms of traction, plaster casts, braces, and combinations of these. External devices are either intended to correct curvatures or to maintain correction achieved by other means. External appliances have their effect on the scoliosis by application of corrective forces. Generally, pressure is exerted against the convex side of the curve with counter pressure applied against a fixed portion of the skeleton such as the pelvis and rib cage (1). Pressure is also applied against the convex aspect of the rib rotation in an attempt to cause de-rotation. Traction tends to elongate the spine and thus decrease curvature (1). External correction devices can be divided into passive and kinetic action modalities. Passive devices apply the principle of steadily applied pressure with no effort required on the part of the patient. The Wilmington brace and the Charleston Bending brace are examples of passive orthoses (1). Passive spinal orthoses are total contact orthosis. This means there is no space for the patient to move in the brace for active correction of the spine (49). The passive form of correction is used in the non-operative treatment approach, but also has significant application in preoperative correction and postoperative maintenance of scoliosis correction. Passive corrective devices include casts and some braces. Kinetic correction involves active participation by the patient (1). The Boston brace and the Milwaukee brace are examples of active orthoses (49). (Appendix 7 for further information about braces, casts, traction and the Cotrels Method.) Achievements of brace wearing Orthotic treatment of idiopathic scoliosis is based on the principle that spinal orthoses have the ability to control progression of spinal curvature (49). Rigid orthoses are commonly custom fabricated and provide the most support to the area being treated. A body jacket or a TLSO controls motion in all planes. Depending on the goals of the TLSO, the design can be modified accordingly. A two-piece front and back design is commonly used post-operatively for ease of application, while a front or back opening single piece design is commonly utilized when treating scoliosis. Velcro straps are commonly used to fasten the closure on all orthoses today (45). It is important for the parents and patients to realize that the purpose of bracing is to keep the curve from progressing as a child grows. While the curve will demonstrate improvement during the time the child is braced, it might revert to its original degree of severity when the use of the brace is eventually discontinued at the cessation of growth. Some individuals do achieve permanent correction, and keep the curve on an acceptable level, thus avoiding surgery. This is to consider a success (1). The most difficult idiopathic scoliotic curves to treat are those with apex at T6 or above. They may in fact be truly unbraceable. Research has reported that high thoracic curves show poor correction regardless of the type of brace used, but if bracing is attempted a CTLSO is required (49). In his book Conservative treatment of juvenile and adolescent idiopathic scoliosis from 1991 Styblo found that 290 brace-wearing patients had a final mean value larger than the value at the start of treatment. This was the case with the lateral curvature, apical vertebrae rotation, and rib hump. The spinal dysbalance showed a slight improvement after treatment. No significant difference was found between the initial deformities and the type of brace worn. The compliance rate was also insignificant. The braces compared were the Milwaukee brace, the Boston brace with superstructure (extension of the brace above the chest), and the Boston brace without superstructure. The Boston brace with superstructure showed the worst response of Cobb angle, Perdriolle angle (measurement of spinal rotation), and rib hump compared with the other two brace types (52). For some patients (20% to 25%) bracing does not work, and unfortunately, it is not possible to predict who they will be. Still parents and physicians can be reassured by the findings for those patients who meet the generally accepted criteria; bracing is a wise course of action (45). Patients with a poor prognosis have a highly structural curve, manifested by poor flexibility on the Adams forward bend test (<50%), a large thoracic rotational prominence (( 3cm), and thoracic lordosis. Thus, the patients with good prognosis are flexible, have a smaller rotational prominence (< 3cm), and have a normal lateral roentgenogram. These patients can also have a poor outcome, but it is less likely to be so (48). Larger curves are said to be stiffer, but according to Dickson this is incorrect. There is no muscle tightness, but the larger the curve gets, the more asymmetrical wedged the contained vertebrae becomes. Thus, it will be progressively more difficult to correct the deformity non-operatively (47). Prediction of outcome of brace treatment To achieve a successful outcome from bracing it is necessary that a highly skilled orthotist or brace maker work hand in hand with the orthopaedist to craft a brace precisely tailored to the patients needs. In many cases an exercise program is also provided. After that, the physician will have the patient return for routine checkups and order x-rays to make sure the brace is doing its job. The physician will prescribe periodic adjustments as necessary. The brace is worn until the physician has determined that skeletal maturity has been reached at which time the patient will be gradually weaned from the brace (45). When epiphyseal growth is completed as evidenced by x-ray confirmation and no progression has been noted in the recent months, the brace may be gradually withdrawn. The patient is weaned from wearing the brace by removal for varying periods during the day. The rapidity with the weaning process varies with the doctor, the course of the patients scoliosis, the severity of the curve, and the dependability of the patient. The brace may be removed for one hour daily with x-rays taken within three months. Progression of the scoliosis may require resumption of wearing the brace full time. Maintenance of the correction may encourage further weaning (1). When stability of the scoliosis has been demonstrated after the patient has been out of the brace eight hours daily, it is usually allowed to continue wearing the brace at night only for six to twelve months. During the process of weaning frequent x-ray measurement of degree of curve (Cobb method) and degree of rotation (measure by any acceptable method) must be ensured (1). Whenever loss of correction is noted resumption of brace wearing may be necessary. This is psychologically traumatic and occasionally rejected by the patient who is now a self-conscious adolescent. It is discouraging to the patient and the family that hard gained correction from years of brace wearing has been lost (1). Loss of correction creates a therapeutic challenge of whether to resume the brace, if so, for how long, or to decide upon operative correction. The latter decision raises the question in the patients mind of the advisability of wearing a brace in the first place (1). In a young child with a 10 to 15 curve without rotation, the brace can be delayed as long as repeated x-ray examinations are taken every three months. As soon as there is indication of approximately 5 of progression, the brace should be considered (1). In a curve of less than 15 to 20 with any noticeable rib angulation or rotation attributable to the thoracic scoliosis, bracing should be considered. Curves of > 20, with or without rotation, are candidates for bracing (1). A late onset adolescent idiopathic scoliosis curve or any other progressive curve of less than 50 may be held in a brace until skeletal maturity, that is, until the iliac apophyses have fused. A brace is not always capable of controlling the curve at this age and fusion may become necessary. However, in general the experience is that the curve is improved by wearing the brace, but relapses back to the pre-brace angle of curvature when the brace is removed after the iliac apophyses have completed their growth are possible. In general terms holding a scoliotic curve in a brace until maturity prevents an increase but does not provide any correction of the curve (13). The extent of brace wearing This is a question of patient compliance, and there is no certain answer to it. One can assume that a brace that is never worn will do nothing and that a brace worn 24 hours per day is doing as much as a brace is capable of doing. The idea of wearing a brace for 23 hours a day as full-time wear was an intuitive decision and not based on hard objective data. In recent years, the Scoliosis Research Society has raised doubt as to whether part-time brace wearing is effective, and if so, how many hours that is enough. Also, one does not know how non-compliance has affected the outcomes of the recently published brace studies (46). Compliance has been said to be better with underarm orthoses than with the Milwaukee brace, but actual studies have not shown any difference. Compliance can be improved considerably by a high degree of patient education, and by strong report between the patient and the treating team. The physical therapist is often of greater value in this communication role than in providing exercises (48). Several studies have demonstrated the importance of the mothers attitude on the childs perception of her own condition and acceptance of treatment. While no one would suggest that adapting physically or psychologically to bracing is easy for children and teenagers, many studies show that after an initial adjustment period, patients who are braced live very normal lives, engaging in appropriate activities, including sports, and that they have good psychosocial adjustment no matter which brace they wear (45). There is a lack of objective data defining what the compliance rate truly is when defining minimal acceptable wearing time. Presently several centres are designing new compliance monitors that will allow clinical studies to be carried out that will answer wearing time or brace dosage questions (46). Di Raimondo reported that the compliance rate was higher in younger patients and decreased, as the patient grew older. Because of the high rate of non-compliance with the full-time brace wear, the part-time brace wear, have been investigated. The brace is worn 16 hours or less every day, and the Cobb angle should be less then 35( (49). Until accurate and precise methods are utilised to objectively measure compliance, it is impossible to analyse the effect of wearing time on good versus poor outcome. Therefore any current statements about the effects of brace compliance on outcome of treatment are purely speculative (46). Pressure from child and parent to abandon the brace is, of course, an important factor in the girl or boy in late adolescence who becomes very conscious of wearing the brace at an age when appearance and social factors are becoming of great importance. Unfortunately, however, until the apophyses are complete and fused it is not reasonable to leave off the brace. In the last year of growth, however, wearing it at night and part of the day seems a justifiable help to the occasional, and understandably, rebellious young adult (13). When the apophyses have completed their excursion, consideration of reducing the hours spent in the brace may be allowed. When the apophyses are fused to the ilia it may be abandoned. This latter step is late, often at 17 to 19 years of age even in girls. When in doubt at the time of initial relaxation of the regime, remove the brace for four hours and re-x-ray. A significant loss implies that the brace should be retained full-time for longer (13). When in doubt about the prognosis when the curve is small, frequent observation without conservative treatment saves some children from ever needing a brace and others some years of freedom. If visits are frequent and curves are measured there is no danger of a curve running out of control (13). A very large percentage of patients would be treated unnecessarily, if all idiopathic scoliotic curves less than 25( were routinely braced (49). Acceptability of the patient, which is very individual, is important if bracing should be initiated. Will the patient accept the deformity if it is of no burden? And if so, will there be any treatment at all? Patients with a curve of 40 have undergone surgery. Others with a curve of 60 may not be that concerned about the deformity and their appearance and receive no treatment (47). 5.1.3 Exercise treatment for adolescent idiopathic scoliosis Exercise is the least expensive, most convenient and readily available form of the current non-operative treatment approaches for the management of idiopathic scoliosis. In 1991 Cassella and Hall questioned its efficiency based on personal clinical observations (53). Surgical correction of idiopathic scoliosis was in 1992 the treatment of choice in the United Kingdom. In Germany physiotherapy with exercise therapy was the sole treatment of patients with a Cobb angle of 20 or less (41). The use of exercises has long been advocated in the treatment for scoliosis. Various exercises, including active, passive, symmetrical, asymmetrical, and manipulative exercises, have been expounded. Cailliet mentions it as universally accepted that exercises alone will not prevent progression of a scoliotic spine, nor will exercises alone correct an existing scoliosis. Exercises have the value that they may improve posture, increase flexibility, and improve general tone, both muscular and ligamentous. Exercise also has a psychological value in that it improves the feeling of well-being and the self-esteem of the patient (1). Cailliet states in his book from 1978 that scoliosis exercises are of two types. He promotes that exercises should preferably be taught to the patient before the brace is obtained, and initiated as a daily practise with and without the brace. The standard conditioning type is done in and out of the brace, and is intended to maintain the strength of the trunk muscles, which may be restricted by the use of the brace. These exercises are aimed at strengthening the abdominal muscles and stressing proper posture. Within the brace, all athletic activities other than violent gymnastics and contact sports are encouraged (1). (See appendix 8, figure 4 for example of exercise treatment.) The other specific types of exercises include those meant to decrease the major curves. These exercises are aimed at: 1. Decreasing the lumbar lordosis. 2. Reducing the thoracic (rib) hump. 3. Forcing out the thoracic depression on the contra lateral aspect of the hump. To do these exercises, the patient pulls away from the pad over the hump and presses forward toward the brace-bar side. A pelvic tilting exercise is practised to decrease the lordosis. Traction within the brace is attempted by what can be termed distraction. The patient forces the head back against the occipital pad and attempts to get taller. Distraction exercises can be taught with the therapist or the parents pushing down on the vertex of the patients head while he pushes up to get taller. This exercise aligns the head over the pelvis, decreases the cervical lordosis and the dorsal kyphosis, and also tilts the pelvis, thus decreasing the lumbar lordosis. This is an excellent postural exercise done in and out of the brace. The patient alone can, if he places a 2 to 10 pound sandbag on top of his head for frequent 10 to 30 minute periods during the day, also achieve this (1). James wrote about different active treatment approaches in his book Scoliosis from 1976. One view was that scoliosis was due to muscle imbalance and that this would be corrected by physiotherapy in the form of strengthening exercises if only they could be carried out frequently, energetically and for a long enough period of time. This is still a popular view. Asymmetrical Klapp exercises, where the patient crawls round in circles opposite of the convexity of the curve, general exercises, and exercises to maintain spinal mobility are still advocated by some therapists. According to James, the negative aspect of active exercises for idiopathic scoliosis is that this sort of treatment is based on pathology for which there is no evidence (13). James mentions that Steindler et al. believed exercises for developing a compensatory curve were important in controlling the condition. However, in idiopathic scoliosis compensatory curves develop spontaneously with the structural curve, and idiopathic curves are very rarely seen without adequate compensation. Therefore, it hardly seems necessary to exercise in order to develop compensation that will occur unaided (13). In 1941 the American Orthopaedic Association reviewed several thousand cases treated by exercises. Their conclusion, briefly summarised, is that exercise when tested by measurement of the curve, were demonstrably ineffective in controlling curve deterioration or improving an existing curve. It was common to find that children with long-standing scoliosis, despite several years of constantly worn braces or plasters, showed steady deterioration of the curve measurements during these years unaltered by the treatment. Usually lumbar curves, often present for many years but untreated, occur just as often as the severe thoracic curves treated with all that is traditionally available; it is the untreated lumbar curves that have remained small. It is obviously not the treatment that has caused such rapid deterioration, it is inescapably the inherent characteristics of the curves revealed, unaltered by any form of treatment or lack of it (13). It is generally believed that physical activity is beneficial to scoliotic subjects for stimulation of respiratory muscles. A study with 20 girls with adolescent idiopathic scoliosis was done to investigate the effect of aerobic training on selective respiratory parameters as well as the ability to perform aerobic work. The girls usually wore a Boston brace but not during aerobic exercise on the cycloergometer machine. Exercise frequency was four times a week with intensity of 80% to 100% for 30 minutes each. The training program lasted 8 weeks. Forced vital capacity (FVC) increased significantly in the training group while it decreased in the control group, also consisting of 20 girls. The results suggest that aerobic training provoked positive adaptations in the training group. A possible explanation could be that scoliotic subjects hyperventilate during sub-maximal exercise, on average 20% more than non-scoliotic subjects. Exercise training may have little effect on the static and dynamic measures of lung function, but it is beneficial for improving ability to sustain high levels of sub-maximal ventilation. Although the training group had a scoliotic curve of 27.4( ( 1.9, it has been documented that subjects with scoliosis exceeding 90 present serious cardio-respiratory implications with significant decrease in daily activity and increased mortality (44). It must always be remembered that the primary purpose for the treatment of thoracic scoliosis is the preservation of normal vital capacity (48). Persuasive epidemiological and laboratory evidence shows that regular exercise protects against the development and progression of many chronic diseases, and is an important component of a healthy and active lifestyle. This seems to be of special importance to scoliotic children (44). According to Branthwaite early onset of idiopathic progressive scoliosis has been shown to be dangerous for heart and lung function, but not late onset. The threshold for heart and lung problems was the presence of the deformity before the age of 5 years. For more than 15 years it has been known that treatment of late onset idiopathic scoliosis has to do with appearance and deformity with its social and psychological deprivation. How the idiopathic scoliosis affects the patient is absolutely crucial in the initiation of treatment. One can ask the question: Is the deformity acceptable for the patient (47)? One specific factor that may be relevant for treatment is the evidence of muscle asymmetry associated with curvature. All studies support a predominance of type 1 fibres on the convex side. There seems to be hyperactivity on this side as well. When 12 adolescent idiopathic scoliosis patients were tested, the lumbar multifidus area was found to be larger on the opposite side of the thoracic curve convexity and on the concave side of lumbar and thoracolumbar curves. These asymmetries were corrected with a torso rotation exercise machine (MedX Rotary Torso Machine) within 4 months, which was associated with significant strength gains. Of course, specific exercise training cannot be proposed to replace standard non-operative brace therapy. Brace therapy, however, as with unmeasured exercise, is certainly complicated by patient non-compliance (54). Compared with age-matched controls, regardless of curve severity or spinal fusion, subjects with idiopathic scoliosis have shown to have similar simple static balance responses when the somatosensory system was stable. But they were significantly more likely to fail the complex, sensory-challenged balance tasks when the somatosensory system was challenged by an unstable position of the feet, particularly when the eyes were closed. Individuals with moderate to severe scoliosis (>25) had significantly higher vibratory thresholds than those with mild curves. These problems should be evaluated and treated when present as part of a conservative management program for patients with idiopathic scoliosis (55). 5.1.3.1 Exercise treatment according to Schroth The three-dimensional treatment according to Schroth is a physiotherapeutic approach to a spinal deformity. It was developed by Katharina Schroth as she intended to correct her own posture and normalise her own scoliotic spine. She designed an exercise program to treat the various deformities and static changes of the scoliotic trunk in addition to the curved spine (41). This treatment method is claimed to be suitable for prevention and treatment of secondary functional impairments as well as for treatment of scoliosis-related pain (42). In fact 85% of the patients think the pain improves or disappears, sometimes only after a few weeks of exercising, and the quality of life is also improved (41). The Katharina-Schroth Hospital in Bad Sobernheim, Germany, only treats patients referred temporarily by orthopaedic surgeons who remain responsible for the patients in the long term. They therefore have no possibility to do an extensive follow-up of their patients (42). The usual treatment program lasts from 4 to 6 weeks, and consists of intensive training. About 1200 patients from eight to 70 years of age attend this hospital every year. 80% to 90% of these patients have idiopathic scoliosis (42). During the in-patient treatment by the Schroth method the patients learn to actively straighten the spinal curves as far as the scoliotic posture permits. The patient performs a large number of active exercises under supervision of a therapist, and with self-correction using mirrors. All the existing spinal curves are subject to the influence of active elongation, active lateral deflection, and active de-rotation. Especially in the thoracic and thoracolumbar regions, performing rotational breathing exercises additionally reinforces the de-rotation. Optimal correction will stretch the postural muscles even on both sides so that the actual structure of the muscles provides a better foundation for the muscle work. This correction is then stabilized by means of deliberate activation of the trunk muscles and by reflex activation achieved by beginning the exercises in an asymmetric and flexed position. The corrected posture must then be internalised by conscious perception of the afferences from muscles, joint and ligaments (42). The patient learns to associate his corrected postural sensation with his corrected appearance. In order to permit correction of posture in a relaxed state too, cushions must be placed in positions suitable for the individually required correction while the patient is lying down. It is also through proprioception that the patient is finally able to transfer the corrected position to his daily activities. The patient always begins by assuming the starting position consisting of inclination (not bending) to the concave side of the thoracic curve and slight inclination forwards in order to activate the correcting portions of his postural muscles. The therapist gives exteroceptive assistance to help the patient to straighten his curve. With the use of mirrors the patient can observe his progression of the postural correction, which is a motivating factor (42). Rotational breathing can only be done effectively after a correction of the posture is done. To correct the posture the pelvis is moved backwards, the trunk forwards to create the opposite shape, making the trunk erect (41). With the help of respiration the ribs can reduce the torsion of the trunk during exercises performed with the Schroth method. On the concave side of the trunk the ribs need to widen from the inside by specific breathing exercises, the opposite way of the depression of the scoliotic posture (inwards and downwards) that is upwards and outwards. Laterally + cranially + posteriorly = three-dimensional, and at the same time the patient should lower the diaphragm muscle. The rotational breathing leads to an increase in rib mobility, vital capacity, and sagittal respiratory excursion. The vital capacity improvement is measured in 95% of the patients treated (41). The patients are meant to adapt their new postures and active exercise techniques to be used further on in life to prevent curve progression (42). The patients who bring their braces can use these outside the exercise program. For those who wear braces 23 hours a day there are made exceptions. They can do the exercises with the brace since the therapy lasts from five to six hours daily. The Boston brace and other low profile braces can be used together with the exercise program (41). Katharina Schroth made some rules concerning what increases a scoliosis, and she tried to make the therapy for scoliosis opposing these effects. She divided the trunk into three blocks. The pelvic and shoulder girdle are rotated in the same direction, but the rib cage, the middle block, is rotated in the opposite direction of these two. This goes for the sagittal plane as for the frontal plane. The more these blocks rotate against each other the more severe the scoliosis is, and with the help of gravity it is likely to become an extreme deformity if it is left untreated. This is why active extension is important in the treatment. It works as an active de-rotation of the spine. During the expiration phase in the form of isometric exercises, the patient develops his active stabilisation (41). The therapists at this hospital explain scoliotic statics to the patient by means of photographs and encourage the patient to exercise alone at home. The next step for the patient will be to integrate what he has learned of exercises and corrective perception into activities of daily life. Thorough information and explanations are given to the patient to make him do the exercises correct, but also to motivate him to do the exercises for one hour daily the rest of his life to keep the scoliosis under control. Information to the patient is also given so that he can avoid behaviour that could increase the progression of the scoliosis (14). Ever since 1958 the three-dimensional scoliosis treatment to Schroth has been taught at the School of Kinesiotherapy in Brussels. It is also taught in Spain, Austria, Switzerland, Brazil, France, and Germany (41). Weiss, who has been working with the Schroth method for years, has this to say about exercises in the treatment of idiopathic scoliosis: Exercise regimens have an established place in the treatment of idiopathic scoliosis. They are generally prescribed as a sole form of treatment in patients with Cobb angles up to 20 and combined with electrical stimulation or bracing in patients with angles of 20 and above. The aims of these exercise programs are: to delay increase in curve magnitude to prevent and treat secondary functional impairment to control pain (42). 5.1.3.2 Exercise treatment in combination with bracing Exercises done within the brace are given to the patient as soon as the brace has been fitted and the patient begins wearing it. Just as exercises alone are of limited value in either correcting or controlling scoliosis, applying a Milwaukee brace without exercises is of limited value. The effectiveness of a Milwaukee brace depends on its constant wearing (23 out of every 24 hours) and daily exercises performed in and out of the brace. The child wearing the brace must be informed of the necessity of continuous wearing and simultaneous exercises and must accept this and cooperate. To insist on a brace for a reluctant or resistant child who also will fail to exercise or to wear the brace, is an exercise in futility (1). James quotes: I remain sceptical of the value of exercises; they are of no use out of a brace, it is difficult to believe that a brace markedly alters the effect of exercises. No scientifically reliable evidence has been brought forward as to its value. Using the simple brace without physiotherapy has proved excellent (13). In addition to the corrective forces applied by the brace, exercises that increase corrective forces are done actively within the brace. These exercises tend to pull the convexity away from one pad and push the concavity toward the opposing pad. De-rotation is also attempted in combination with motion toward the midline. Exercises are also done out of the brace through the range of motion that is otherwise prevented by the brace (1). Physical therapy has often played a significant role in the initially ineffective conservative treatment of scoliosis. Not surprisingly, the pioneers of bracing also recommended physical therapy as an adjunct to the brace treatment. In later years, this enthusiasm has waned in many places, as more knowledge has accumulated about both the natural course of idiopathic scoliosis, and about the way bracing can change it. Today, regular exercise should be recommended to prevent muscle atrophy and stiffness from developing while in the brace. Accordingly, many scoliosis patients are referred to a physiotherapist (40). The combination of Milwaukee brace and physiotherapy is the standard management of a flexible idiopathic scoliosis between 20( and 50(. The indication for this therapy is limited to the period of accelerated growth (40). The Milwaukee brace was developed from a passive extension brace to a semi-active incentive brace. Better and faster therapy results can be obtained by the addition of physiotherapy. Exercises strengthen the corrective attitudes in a brace, preventing a relapse of the deformity. Written guidelines provide assistance for both patient and physiotherapists. Ambulatory checks are performed to measure whether and which exercises are executed. As recommended by Blount, a contracture of the hip muscles is treated, if necessary, to straighten the pelvis (40). The first training program serves mainly the maintenance of the strength of the muscles, and can be executed both with and without the brace. The gradual rise from the reclining position strengthens the back, abdominal and seat musculature. Next, the straightening of the pelvis is learned in the reclining position with bent knees and hip joints, and later with straight legs. The physiotherapist checks the correction by placing her hand under the small of the back. From the following exercises we expect an additional posture correction. The tailors position facilitates straightening the pelvis in exercises while seated. If the pelvis is asymmetric, the seat must be supported accordingly, to achieve an even pelvis. One or two staffs aid the extension of the spinal column. In the prone position, the back, abdominal, and shoulder musculature is symmetrically strengthened. If the patient pulls the rib cage away from the pad, the primary curve is also corrected, while the Milwaukee brace prevents an increase of the compensatory curve. The same effect can be achieved with exercises in sitting with the hands positioned on the girdle. When performing the Klapp crawling exercise, muscle strengthening is emphasized. Performing the posture training in front of a large mirror gives a visual feedback (40). It is more important to teach easy exercises that the patient masters, than a complicated exercise program. It is advised for the patient to practise twice daily for at least 10 minutes, and to perform most of the training in the brace, since this facilitates the correcting movements and prevents evasive movements. It is essential to control the progress at least every six months, to stimulate the patient, to check the brace, and to find the right time for an operation if the scoliosis progresses. During a growth spurt, and at the beginning of the treatment when the correction is the greatest, the brace must be adjusted with shorter intervals. Importance of the physiotherapy is especially noted during weaning of the brace (40). Blount stressed the importance of exercise in the brace treatment of scoliosis. Although some good results can be obtained by the use of a Milwaukee brace without physical therapy, the improvement is usually less and is obtained more slowly than with the addition of a simple exercise program. All patients are encouraged to increase their participation in sports and general ADL (activities of daily life). All patients are also given supplementary exercises under the direction of a physical therapist. Although some exercises are performed without the brace, the brace should not be removed just to facilitate complicated routines that may bore the patient. Blount also describes active correction of the spine by means of two types of exercises; general exercises and correcting exercises. General exercises are done to strengthen the torso. The tilting of the pelvis is a basic first step. It is important to maintain the strength of the anterior abdominal muscles, since they are synergists to the lower spinal muscles. The traditional sit-ups and push-ups are recognized by Blount as good conditioning exercises for patients with scoliosis. Hyperextension is routinely exercised (40,43). The correcting exercises are done with the brace, and are performed to de-rotate the spine. The patient should tilt the pelvis, take a deep breath and arch the spine. The therapist can then guide the patients movements in the brace encouraged by touch. The patient presses her body against the brace, squeezes the fingers of the therapist, and the spine should de-rotate. Shifting technique is also performed in the brace. If there is a double curve it is really hard for the patient to perform this if the brace is not used. The patient may be able to correct one curve but the other one will still be present or even become worse. The pressure from the pads in the brace will help the patient to do the shifting correct. The pads will advance with their pressure as the patients spinal curve is improving. By experience, correction for curves of 40 in growing children by traction have been proven much less effective than the three-point, axially directed pressure system. Traction becomes however more important when the curve reaches 90, and exceeding 100 traction is all-important (40,43). A different form of treatment is included to show that there are still testing and research being conducted to find out new methods for the treatment of adolescent idiopathic scoliosis. A study from 2001 examining the use of a device called Micro Straight, has given positive feedback in postural self-awareness of 16 patients with progressive adolescent idiopathic scoliosis. The patient wears the instrument like a long necklace. The device is a further development from an electronic postural training device developed by Dworkin in 1982. It is designed with a tone alarm for poor posture, measuring the spinal length continuously. When the patient starts slumping or falling back to his habitual posture, the alarm goes on after 20 seconds. The device has a data-recording capability so that measurement for patient compliance and progression can be evaluated. The device is in a test stage, but if it is shown to be of benefit for patients with kyphosis and scoliosis, it would surely be more patient friendly and comfortable than a brace (56). 5.1.3.3 Side-shift therapy In view of the drawbacks associated with the existing treatment methods, Metha introduced, in the 1980s, the method of active auto-correction (4,33,57). She suffered from idiopathic scoliosis, and started experimenting on herself with different treatment options (A). An alternative form of treatment for adolescent idiopathic scoliosis was needed. This method should impose no external constraints by day or night, be minimally inconvenient, and be capable of obtaining results at least as good as those obtained by the existing methods (33). The side-shift therapy is a therapy performed in the frontal and sagital plane (4,57,33). A side-shift is described as a side ways movement of the thorax to left or right in the frontal plane. The main principle consists of treating the primary curve by balancing the spine (33,57). The frequent repetitions of this manoeuvre can stabilize and even correct an early idiopathic scoliosis (33). This therapy has been used at Sint Maartenskliniek, Nijmegen, since 1985 on patients with adolescent idiopathic scoliosis and curves between 20 and 35 degrees (A). This sliding side-ways movement is performed in the direction of the concavity of the thoracic curve. In this way an active correction of the curve takes place (4,33,57). Most idiopathic scoliosis has a right convex thoracic (thoracolumbar) curve with a compensatory left convex lumbar curve (57). In this case, the thoracic side shift should take place towards the left and the concavity. Idiopathic scoliosis is a three dimensional problem, but treatment is focused only on two planes (A). 95% of patients with adolescent idiopathic scoliosis have a lordoscoliosis. One seldom sees kyphoscoliosis in adolescent idiopathic scoliosis, although it may look like this due to the rib hump appearing in some patients. The treatment for the lordoscoliosis consists of exercising flexion in the thoracic area combined with the side shift. Combining these two movements creates a derotation of the vertebrae. By exercising in two planes one can get a three dimensional effect (4,33,57,A). The principle of active correction by shifting the trunk sideways over the pelvis is not new (33). As early as in 1929, Steindler used it in his compensatory treatment of scoliosis (33). The side-shift is easy to learn. With the aid of visual feedback from a mirror, and gentle fingertip pressure applied laterally to the convex side of the rib cage and the contra lateral hip the child adapt to the movement (33) (fig.7).  Figure 7 (33). A girl with a right thoracolumbar scoliosis being shown the side-shift. The mirror enables the child to see that in returning to the habitual posture her body slumps passively into the position of deformity. The child should also be shown standing radiographs of the spine taken in the relaxed and in the side-shift position to help him/her recognise the habitual posture as the position of deformity and the side-shift as the position of correction. Seeing these radiographs may make the child understand why she is required to perform the shift, and to acquire the habit of thinking shift. Other than the requirement to shift frequently through the day, every day, the child leads a normal life. Parental supervision is necessary each day during the first week to see that the shift is done correctly (33). The main part of the therapy is focused on activity level (4,57,A). Children spend much of their day in a sitting position, and sitting in front of a mirror is the starting position for the side shift therapy. It is important that the weight is equally divided on both gluteis to create a good sitting balance. Most patients with idiopathic scoliosis have a decreased sitting balance. This creates a position of the pelvic that is not horizontal. Exercises for the sitting balance are given, and stabilising centrally is important to avoid making the curve worse. When the sitting balance is corrected and controlled, the side-ways shifting movement can be learned (57). The child is thought to shift the trunk away from the curve convexity as far as the spine will allow, to hold this position for about ten seconds and then relax into the rest position (33). It is important to strive for symmetry, and to create equilibrium in the corrected position. For those patients that have a good corrected posture, trying to normalise the curves in the sagital plane is a second task. With only a lumbar curve, side shift exercises are not given. The exercises in these cases consist of pelvic training in addition to having a good posture of the thoracic area (57,A). Children with a marked lumbar lordosis are instructed first to obliterate the lordosis by reverse pelvic tilt and then to shift sideways (33). The secret with this treatment lies in the fact that it takes time to change a posture. With a lot of time a new posture is learned and it becomes automatic. During the weeks/months that the treatment takes place, the patients receives instructions to all the time try to increase the amount of time he/she can hold the corrected position. The shifting is then made more difficult by exercising in different environments, and trying to keep the corrected position when carrying out daily activities. Examples of this are while having breakfast, watching television, doing homework, at school, and combined with other tasks. When doing homework and having a right scoliosis, the paper should be placed to the left on the table. By integrating the exercises into daily activities it is made more motivating for the patients to continue exercising, and this may increase the compliance (4,33,57,A). The corrected side-ways shifting position is maintained with only a small and simple movement. This can anyhow be very difficult for some patients. Young children (under 12 years of age) and patients with decreased postural feeling are more difficult to teach exercises. Due to this these patients are less suited for this type of therapy (57,A). Finally the patient have to automatically keep the corrected shifting position in standing and walking. It usually takes many months before the patient can do this. It is important that the treatment program is individual, and that the therapy is made in successive steps. Giving the patient enough time is paramount to a positive effect of the therapy. The treatment outcome depends much on both patient and physiotherapist. The patient has to regularily exercise. The compliance among teenagers is often not high. It is therefore important with a stimulating and motivating physiotherapist (57,A). This physiotherapy treatment should continue until the patient reaches the end of the growth spurt. This is approximately 16 years of age in girls, and some years later for boys. The frequency of treatment is one half hour once a week. When the patient has received good instructions concerning shifting and exercising, a control once a month is sufficient. The patient should also have a medical control every third or fourth month (57). In addition to the side shift therapy, strengthening muscles of the back and abdominal is important. The concave part of the scoliosis is in most patients with idiopathic scoliosis stiff, and mobilisation exercises are considered to decrease this stiffness. Patients with idiopathic scoliosis often have decreased proprioception. Exercising walking with eyes closed is appropriate, although not very functional, due to the fact that these patients tend to go to one side. It is important for these patients to learn about their bodies. With increased body awareness and spatial feeling, it may be easier to correct the body (A). Thoracolumbar and low thoracic curves respond best to the side-shift. Lumbar curves respond less. For a double curve with right thoracic and left lumbar convexity, the side-shift away from the thoracic convexity is used (33). The side-shift has the advantage over the other methods that it can be used as maintenance therapy to prevent progression in adult life (33). To explain how the side-shift works, a brief description of what happens when a curvature develops from a normal spine is necessary (33). The first sign of an imbalance in the frontal plane in the straight column is a slight tilting of a lumbar vertebra. With development of a lateral curve, the tilted vertebra becomes the lower-end vertebra. The area around the lower-end vertebra becomes the target zone for the deformity to create imbalance and produce scoliosis. The vertebras in this area moves en-bloc and the direction of its movement controls the size of the curve. The side-shift works by opposing the deforming forces, by a counterforce generated by the childs own musculature, to move the area around the lower-end vertebra back toward the midline vertical. This principle of active correction is quite different from the passive correction by brace where the main thrust of the three-point pressure system is directed at the apex of the curve (33). By allowing the treatment of smaller curves, the side-shift therapy as an auto correction treatment, may extend the scope of prevention to complete correction in some cases (33). This form of therapy is accepted well by the patients. The treatment is functional and the children avoid the application of a brace. The cosmetic factor is especially important for adolescent girls. The use of a mirror to visualise the correction by a side shift is an important motivating factor for the treatment (57,A). The success of the side shift therapy is measured in prevention of progression. Having a curve of 25( at 12 years of age, and this curve still measures 25( at 16 years of age, indicates a 100% prevention success. Some patients also have a decreased angle as a result of the side shift therapy, but this is not the main goal for this therapy. The main goal is to prevent progression of the curve (4,57,A). This method of side shifting is also used in Switzerland and the USA. It is not used in England. England, as many other countries, has no school screening. In the Netherlands school screening is performed on everybody. This makes it possible to detect an adolescent idiopathic scoliosis earlier, and to start treatment at an earlier stage compared to what is possible in for example England (A). The possibilities of earlier treatment and more ready acceptance by the patient are important considerations. They are, however, not in themselves sufficient reasons for recommending a method unless the results it obtains are at least as good as those had by existing methods (33). The results from a preliminary report on the application of side-shift to 35 children with adolescent idiopathic scoliosis appear to indicate that they are comparable with those reported by braces or electrical stimulation (33). For 35 children with an initial Cobb angle of 15 to 42 degrees, the Cobb angle had either decreased or remained unchanged in 71% (33). The level of prevention of progressive deformity by the side-shift is about the same as by the other methods (33). The inability to ensure that the side-shift is done often enough and to its full limit is the main and only drawback of this method (33). In general, the children co-operate fully in the first six months. However, thereafter they slacken their effort. Having a family member with scoliosis or a passionate determination to avoid bracing, contributes to compliance. Older girls also comply better because they are more aware of their body image and wish to improve it (33). Since there are no absolute criteria for discriminating at an early stage between progressive and nonprogressive scoliosis, the decision to start treatment is postponed until the curve has increased to an arbitrary limit. In general, a curve is contained at the level at which treatment is started and any correction obtained during treatment is lost after it is discontinued. There is a consensus to begin treatment at around 25-30 degrees, but earlier treatment might give better results. The reluctance, so far, to treat smaller curves is because of the psychological hazards of subjecting normal children over a prolonged period to the discomfort and inconvenience of bracing. The side-shift therapy does not in any way restrict the childs daily life or interferes with sleep. Because of this side-shift therapy makes it ethically justifiable to begin treatment sooner (33). 5.1.4 The role of the physiotherapist There is in general limited information to be found about the role of the physiotherapist in the assessment and treatment of a patient with adolescent idiopathic scoliosis. The physiotherapist participate in the various exercise programs, and they often play an important role in brace treatment and postoperatively. In this project, the role of the physiotherapist will be integrated into the description of the different treatment alternatives. Postoperatively, the physiotherapist has an important role in guiding, activating, and instructing the patient. Right after the operation the patient is given breathing exercises to stimulate the normal breathing pattern (4). Forced expiration technique and pursed-lips breathing exercises are used to stimulate the inspiration and the expiration. In addition, exercises for the lower extremities are given to stimulate blood circulation, and to increase strength and mobility. The physiotherapist aids the patient in the return of daily activities like sitting, walking, and walking stairs. The biggest problem for many patients post-operatively is the feeling of having a too straight spine. Being used to a curved spine requires that the body adapts to the new straight spine. This new body feeling may cause some patients to develop a hypertonic state in the muscles of the back, and the physiotherapist can give relaxation exercises to the patient (4). Before the patient may go home, the physiotherapist gives advices and instructions on how to move and live to make sure the healing process is getting the best possible conditions (4). The role of the physiotherapist for idiopathic scoliosis is among other things to maintain or improve the mobility of the spine and related joints. Their task is also to aid in the improvement of muscle function, and to give instruction and advice regarding in particular maintaining a symmetrical posture. The physiotherapist should assess the motorical development of the child, and pay special attention to the symmetrical development. When necessary the physiotherapist should correct and treat the developmental abnormalities (4). In the majority of mild idiopathic scoliosis cases, physiotherapy can help (58). The physiotherapist can give an individual posture and muscle imbalance assessment. In addition he/she can set up an exercise program to strengthen weak muscles and stretch shortened muscles. The physiotherapist can give advise on posture, back care, and how to alleviate stress on the spine with the use of appropriate furniture and correct back packs. It is important to monitor the condition regularly, and when necessary the physiotherapist should refer the patient to a medical assessment. Sometimes the patient is referred to physiotherapy for exercises together with wearing a brace (58). When exercises are prescribed in addition to bracing, it is desirable for the patient to have close contact with a physiotherapist (1). The therapist can instruct in the exercises, supervise the exercises so that they are done properly, and modify them as the curvature dictates (1). The physiotherapist, being a friend and a member of the team, is in an excellent position to evaluate the emotional reaction of the child and the parents to the entire program. The physiotherapist should be able to answer questions about problems of clothing, sitting comfort, school and physical-education activities, and social activities etc. arising during the program (1). Descriptive research about articles on screening and treatment of AIS Introduction In order to contribute to determine the effect of different treatment methods and handling over information about screening procedures related to adolescent idiopathic scoliosis, a descriptive study has been carried out. It was done in the form of a non-experimental descriptive research, which is used to systematically describe and interpret conditions or relationships that already exists. These designs are used to gather information about conditions, attitudes, or characteristics of individuals or groups of individuals. The purpose of a descriptive research is to document the nature and meaning of existing phenomena at a specific point in time, to describe how a phenomena changes over time, and to explore relationships among phenomena. It is not necessary to test a hypothesis, but it may involve the use of guiding questions to generate data or to characterize a situation of interest. These kinds of studies are intended to present new information, and it may enable us to understand what exists in nature. It can be used to investigate patterns of developmental change or to establish normative values (59). This chapter contains a set-up of the design and method of the project. The purpose of the descriptive research was not primarily to find all existing works on the subject, but to get an overview over a representative selection of scientific published studies and information concerning the subject adolescent idiopathic scoliosis in relation to screening and treatment. 6.1.2 Method of the descriptive research Information about adolescent idiopathic scoliosis, screening, and treatment was obtained from the following sources; interview with an expert person in Norway and an expert person in Holland, search in different databases, on the Internet, and in books. Relevant persons, associations, and universities were contacted, and two libraries were used: library at Fontys University of Higher Professional Education (Study landscape) and NIWI (Nederlands Instituut voor Wetenschappelijke Informatiediensten). For further details about books, web sites, databases, and articles used, see the list of references (chapter 10.1) and appendix 4. Some of this information was used to build up the theoretical framework of this project, and the articles were used to answer the two main question of this project. The information used to answer the background question was mostly found in books and on the Internet. To build up a theoretical framework concerning the subject of idiopathic scoliosis, screening and treatment, it was necessary to collect information from many different sources. See chapter 2.1, 3.1, 4.1, 5.1 and reference list (chapter 10.1) for further details. Relevant information was searched for on various web sites. The validity and reliability of the used web sites were tested. The following web site was used for this test:  HYPERLINK http://www.nelh.nhs.uk www.nelh.nhs.uk. The information found on different web sites was read and compared, and used to build up the theoretical framework in part 1. All information found on Internet was assessed using inclusion and exclusion criterias (see below). In addition, books in the two libraries used were assessed for relevant literature based on inclusion and exclusion criterias (see below), and this information was also used in part 1 of this report to build up the theoretical framework. The project group visited Sofies Minde, a scoliosis competence centre in Norway. There was conducted an interview with an expert person: orthopaedic engineer Svein Ivar Olsen. The interview was worked out before this visit, and this was an interview with open-ended questions. This approach was chosen based on the fact that an open-ended question allows the responder to answer in his/her own words. Additionally, with the use of open-ended questions the interviewer can clarify by using follow-up questions. The purpose of the interview was to increase the knowledge within the project group concerning the screening and treatment situation in Norway related to adolescent idiopathic scoliosis. The information gathered was used to build up the theoretical framework in part 1. For questions for the interview see appendix 2. The project group visited Sint Maartenskliniek, a scoliosis competence centre in Nijmegen. An interview was carried out on an expert person; Jan van de Braak, and the project group were given a tour through the facility. The members of the project group observed the treatment procedures used at this facility. A video containing an assessment and the build-up of a treatment was shown, and Jan van de Braak commented it. The information gathered was used to build up the theoretical framework in part 1. For questions for the interview see appendix 2. Relevant persons, associations and universities were contacted for information about adolescent idiopathic scoliosis. The persons contacted were: Jan Harald Lnn and Bredo Glosrd. The associations contacted were: Norsk Fysioterapeut Forbund (The Norwegian physiotherapy association), Norsk Forening for Ryggforskning (The Norwegian association for back research), Scoliosis Research Institute, the National Scoliosis Foundation (NSF), and Scoliosis Research Society (SRS). The universities contacted were: NTNU (University of Trondheim, Norway), University of Bergen, Norway, University of Oslo, Norway, University of Troms, Norway. These persons, associations, and universities were contacted by e-mail. Questions concerning the subject adolescent idiopathic scoliosis and information about relevant articles and/or web sites were asked for. The web sites and articles these persons and associations referred to were also found by the members of the project group while conducting their search. This fact may indicate a higher reliability of the web sites and articles used for this project. Information and articles were selected by searching in the following databases in the period 01/04/02 to 12/04/02: Medline, Cinahl, and Doconline. Special databases like Vubis and Picarta were also searched for information, together with large search engines like  HYPERLINK http://www.pubmed.com www.pubmed.com,  HYPERLINK http://www.yahoo.com www.yahoo.com, and  HYPERLINK http://www.altavista.com www.altavista.com. The following words were used as search words; active exercises, adolescent, aetiology, bracing, degree, detection, diagnosis, exercise, idiopathic, infantile, intervention, juvenile, physiotherapist, physiotherapy, physical therapy, prevention, prognosis, progression, scoliosis, screening, signs, symptoms, and treatment. These are the search words in English. The same words were searched for in Norwegian (see FLP format, appendix 1). The search words include key words, free text words, and MESH headings, and these words were used with Booleans such as AND/NOT/OR. The search words were used both alone and in combination, and synonyms were also used. The searches in the different databases were divided within the members of the project group. After completing the search, a double check was conducted by another member on all databases to increase the validity of the search. For more detailed information see appendix 1 and 4. After finishing the search, 46 articles were copied. 37 of the articles were found when searching on the different databases. Searching on the Internet gave an addition of 3 articles. The rest of the articles were found in magazines, in the reference list for already included articles and from Sint Maartenskliniek. All the articles were read and judged by two persons. After this the found studies were included or excluded based on the following criterias: The article/information has to be relevant regarding adolescent idiopathic scoliosis. The article/information has to be written in Norwegian, English or Dutch. - Main focus on information from Norway and Holland, but relevant literature from other countries will be included. - The article/research has to be found in full format. The article/research/information must cover one or more of the key words described above. Patient: a person (sex is unimportant), with adolescent idiopathic scoliosis from 9 years of age until the growth spurt stops. Adolescent idiopathic scoliosis without the influence of other disorders and diseases. The year 1966, when Medline started, and more recent material is set as time limit for the use of articles/information. All relevant research material concerning adolescent idiopathic scoliosis from health care institutions can be included. Articles/information containing active exercises and/or bracing can be included. Articles/information containing screening of adolescent idiopathic scoliosis can be included. Articles/information containing quality of life in relation to adolescent idiopathic scoliosis can be included. The name of the author is not relevant. Articles with surgery in the main-title will be excluded. A manual search of the reference lists in the included articles was carried out. The result from this search was an addition of 3 relevant articles. Inclusion and exclusion criterias were applied on these additional articles. After applying the inclusion and exclusion criterias, the articles were divided in two parts based on its content. One part contained articles about screening and diagnosis (part A), and one part contained articles about treatment and prevention (part B). The number of articles about screening was 6 before data extraction, and 23 articles about treatment were included for data extraction. A data extraction was conducted on the included articles by using a data extraction list (appendix 3). Two members of the project group for each article conducted the data extraction. This list was used in order to extract the information of all the material found. The purpose of the data extraction was to make an evaluation of a systematic review of controlled clinical trials or reviews of diagnostic and/or therapeutic literature. Included in this data extraction an assessment of the methodological quality was carried out using the Pedro Scale (appendix 3). The exclusion of articles after data extraction was done on the basis of a too low methodological quality, or by the fact that they did not contain the needed information. The result of this data extraction was 5 articles about screening, and 7 articles about treatment. These articles were the basis for the data analysis and data synthesis. The analysis and synthesis of data includes what is the exact result of the data extraction. This material is presented in the result chapter of this report. See chapter 7.1 for results and chapter 8.1 for discussion and conclusion. See appendix 5 for an overview of the analysed articles presented in the result section of this report. 7.1 Results 7.1.1 Introduction This is the presentation of the found articles after the literature search. After completing the selection of the articles, based on inclusion and exclusion criterias and the data extraction list, the members of the project group had found 12 articles with relevance to screening and treatment of adolescent idiopathic scoliosis. To provide an overview, the list of all the articles included in the result chapter will be presented. A. Articles about diagnosis/screening: 1. A study of the diagnostic accuracy and reliability of the scoliometer and Adams forward bend test. 2. Screening for idiopathic scoliosis. 3. An evaluation of the Adams forward bend test and the scoliometer on a scoliosis school screening setting. 4. School screening for scoliosis. 5. The efficacy of school screening for scoliosis. B. Articles about treatment/prevention: 1. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. 2. A meta-analysis of the efficacy of non-operative treatments of idiopathic scoliosis. 3. Adolescent idiopathic scoliosis. The effect of brace treatment on the incidence of surgery. 4. Adolescent idiopathic scoliosis: Treatment with the Wilmington brace. 5. Effect of exercise, bracing and electrical surface stimulation on idiopathic scoliosis: a preliminary study. 6. Influence of an in-patient exercise program on scoliotic curve. 7. Treatment of idiopathic scoliosis with side-shift therapy: an initial comparison with a brace treatment historical cohort. After the data extraction, five articles concerning screening for adolescent idiopathic scoliosis were found relevant to analyse further. Of these five articles, three were clinical trials and two were systematic reviews. This analysis is described and will be presented in 7.1.2. There were a total of eight clinical trials found concerning brace treatment, but after data extraction, only five of these were used in the results to find out if treatment with a brace has any effect on the patients with adolescent idiopathic scoliosis in relation to treatment and prevention. No articles were found that evaluated active exercises as a treatment form in a clinical trial setting. The project group could only find two articles directly related to exercises as treatment for adolescent idiopathic scoliosis. The article about the Schroth exercise regime was a review article, and was therefore used basically as informative material in the theoretical framework. Still the article is included in the result section due to the importance of its results. Only one article concerning the active side-shift therapy was found. This was a historical retrospective study. A historical retrospective study involves the examination of data that have been collected in the past, and it is often obtained from medical records or surveys (59). These studies are a part of ex post facto research, which means the researcher does not have direct control of the variables under study because they have occurred in the past (59). Due to the limited amount of information found concerning active exercises in relation to treatment of adolescent idiopathic scoliosis, these two articles were included in the result section. The articles concerning treatment for adolescent idiopathic scoliosis is described, and will be presented in 7.1.3. In total, for both screening and treatment, eight clinical trials were analysed. A clinical trial, or intervention study, is the most rigorous epidemiologic approach and is considered the gold standard for clinical research. A clinical trial is a prospective study comparing the effect of an intervention against a control. The clinical trial design represents the strongest evidence for causality of any epidemiologic approach. The most important feature of this design, which is not present in case-control or cohort studies, is the ability to randomly select subjects and randomly allocate treatments, strengthening the internal and external validity. Non-randomised clinical trial may also involve the comparison of an intervention group with historical controls who have received standard treatment, but this approach usually provides limited confidence in outcomes (59). In addition to the clinical trials three systematic review articles were analysed. These were included due to the limited amount of information found. A systematic review is a review of a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant research (59). It turned out that analysing reviews for methodological quality using the Pedro scale was more difficult than anticipated. Information about this analysis will be presented when it was possible to obtain. This lack of possibility to assess the methodological quality totally has been taken into account when interpreting the results of the articles concerned. 7.1.2 Screening The result of the assessment of the methodological quality using the Pedo-scale is included below (table 3). It was only possible to apply the Pedro-scale for the three clinical trials. This is because the reviews are comparing different clinical trials, and specific information concerning the methodological set-up is not included. Still, the review articles are of value due to their broad field of expertise. The author of a review article has the possibility to compare old science with the latest research, and to reveal which articles that are reliable and valid. The two review articles of Karachalios et al. and Morrissy are included in this report due to their ability to focus on several important aspects regarding screening. A review article can provide the reader with several opinions and views, which is not possible with a clinical trial. The two review articles are published within the last four years in well-established orthopaedic magazines. To be able to increase the validity of the report, it was necessary to include these articles due to the amount of important information they contained. Table 3: Outcome Pedro-scale; screening Pedro-scale, screening.1.2.3. 1.Eligibility criteria were specified.YesYesYes 2.Subjects were randomly allocated to groups.YesNoYes 3.Allocation was concealed.YesNoYes 4.The groups were similar at base line regarding the most important prognostic indicators.YesYesYes 5.There was blinding of all subjects.YesNM*Yes 6.There was blinding of all therapists who administered the therapy. YesNoYes 7.There was blinding of all assessors who measured at least one key outcome.YesNoYes 8.Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups.YesYesYes 9.All subjects for whom outcome measure were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by intention to treat.NoNoYes10.The results of between-group statistical comparisons are reported for at least one key outcome.YesYesNo11.The study provides both point measures and measures of variability for at least one key outcome.NoNoNo *NM = Not Mentioned The following section is an overview of the results of the data extraction for the articles concerning screening of adolescent idiopathic scoliosis. In addition a summary of each article will be presented. 7.1.2.1 A study of the diagnostic accuracy and reliability of the scoliometer and Adams forward bend test. (37) This article by Cte et al. was published in Spine magazine in 1998, and wants to estimate the sensitivity, specificity, and predictive value of the scoliometer and the Adams forward bend test. The authors are of the opinion that a non-invasive examination technique is needed in the assessment of idiopathic scoliosis, since repeated radiographs have proven to increase the risk of cancer. This article was chosen, because it is one of the few trials that seem to be quite reliable and valid in the spectre of scientific studies concerning screening of adolescent idiopathic scoliosis. In a clinical trial it is important to ensure that the methodological quality is of sufficient character to prove its validity and reliability. The eligibility criterias are described in the study. All patients referred to a university hospital paediatric scoliosis clinic for evaluation of adolescent idiopathic or congenital scoliosis were eligible for the study. The authors also included patients with congenital scoliosis, who are more likely to have true lateral curves with little rotation, to test the scoliometer and the Adams forward bend test on a wide range of curve pattern and magnitude. Patients who presented with scoliosis of other known aetiologies, and patients who could not perform the Adams forward bend test were excluded from the study. 163 patients were presented to the scoliosis clinic between February 22nd and June 21st, 1994, and 105 patients met the inclusion criteria (87 girls and 18 boys). All patients in the final sample are described regarding corrective surgery, magnitude of curve, apex of curves, and number of curves. Since the clinic is specially designed for paediatric scoliosis, and there is no control group, it is not a randomised selection. However, it would be very difficult, if not impossible, to have a totally randomised group of subjects, since the prevalence of adolescent idiopathic scoliosis is very low. It is difficult to say if all the subjects were similar at baseline regarding the most important prognostic factors, since the difficulty with adolescent idiopathic scoliosis is to determine which curve that will progress and which will not. The two residents performing the measurements were blinded to each other, and scoliometer measurements were performed independently and by convenience. The authors have included a highly advanced statistical analysis to certify and increase the validity and reliability of their study. One bias that could be mentioned is the possibly inaccuracy of the scoliometer to measure exact numbers, since the mercury ball is relatively large compared to the increments on the instruments scale. This could make it difficult to give exact value of the measurement (37). Although controversial evidence exists regarding reliability and validity of the scoliometer, it has been recommended as an adequate clinical instrument and outcome measure for scoliosis research, and screening procedures. In this article, the authors investigate the reliability and diagnostic accuracy of the scoliometer and Adams forward bend test in the evaluation of patients with adolescent idiopathic or congenital scoliosis presenting to a tertiary center. The examiners used the same measurement instruments, and they placed the scoliometer on the thoracic or lumbar spine as the patient performed the Adams forward bend test. If this position showed trunk asymmetry the Adams forward bend test were recorded as positive. Depending on the location of the thoracic rotational prominence or lumbar flank prominence, the examiners asked the patients to flex forward until the hump reached horizontal plane. The examiners placed the scoliometer at the level of the most prominent aspect of the hump, with the 0 mark located over the spine. The estimated apical segment, degree of trunk rotation, and the side of the hump were factors recorded. Scoliometer measurements were obtained from the thoracic and lumbar regions on all patients included in the study. Standing full-spine posterior-anterior and lateral scoliosis radiographs were obtained for each new patient referred to the clinic. Patients who returned to the clinic for follow-up were radiographed in the posterior-anterior position. All patients had his or her Cobb angle measured by the same experienced orthopaedic surgeon. The authors selected the Cobb method as their gold standard. The same measurement instrument was used throughout the study. Patients with more than two curves had the uppermost and lowest curves measured. An independent study member entered all data recorded into a computer database. The interexaminer agreement for the scoliometer proved to be excellent in the thoracic spine and substantial in the lumbar spine (appendix 9, table 1). The interexaminer measurement error showed poor precision for thoracic and lumbar scoliometer measurements. The interexaminer agreement for Adams forward bend test is substantial in the thoracic spine and poor in the lumbar spine (appendix 9, table 2). The Adams forward bend test was more sensitive than the scoliometer in detecting thoracic curves measuring 20 or more by the Cobb method (appendix 9, table 3), and the same findings are reproduced in the lumbar spine (appendix 9, table 4). Table 5 (appendix 9) and table 6 (appendix 9) give the age-, gender-, and history-of-surgery-specific sensitivity and specificity estimates for the thoracic curves and lumbar curves. The sensitivity and the specificity of both methods do not vary with age and gender; however, the scoliometer is more sensitive in evaluating thoracic curves of subjects with previous surgery than subjects without surgery. The surgical scare could influence the examiner bias at this point. The reliability of the scoliometer is questionable. The authors of the study believed that follow-up measurement of less than 5 in the thoracic spine or 6.5 in the lumbar spine could not be conclusive of curve progression. This strongly suggested that the scoliometer would not be responsive to clinically important changes in curve magnitude during the follow-up period of the patient. The high number of interexaminer error associated with scoliometer could be related to several factors. The precision of the instrument itself could be a potential source of measurement error, and locating the exact apex of the curve was not identified in a consistent manner by the examiners. Performing the Adams forward bend test in a consistent manner also proved to be difficult for the examiners involved. The authors believed that the scoliometer should be at least 90% sensitive in detecting curves measuring curves 20 or more. The result from the study demonstrated that the scoliometer did not fulfil that important criterion. In the thoracic spine, its crude level of sensitivity (71%) was significantly lower than that of Adams forward bend test (92%). The authors suggested by these numbers that Adams forward bend test remained a better first-line procedure in the assessment of thoracic scoliosis. The authors were confident that their sample included a wide range of scoliosis severity, which is crucial since a study of diagnostic tests must include a spectrum from no spinal curvature to severe scoliosis. Increasing the cut-off point resulted in an unacceptable decrease in sensitivity. The scoliometer significantly increased the ability to diagnose a thoracic scoliosis by 22% over chance alone, but is associated with a large number of false-negative results. The scoliometer possesses adequate interexaminer reliability, but its weak precision and inadequate diagnostic accuracy limits its clinical usefulness as an outcome instrument. Based on the results obtained by the authors, they recommended that the Adams forward bend test and the full-spine radiograph remains the diagnostic methods of choice in evaluating scoliosis. 7.1.2.2 Screening for idiopathic scoliosis. (60) This article was written by Montgomery and Wilner, and was published in Acta Orthopaedica Scandinavica in 1993. The clinical trial took place in Malm, Sweden, at two separate intervals, between 1971-76 and 1978-81. The authors wanted to assess whether a screening program would decrease the rate of surgery. This is a clinical trial with few subjects involved, which may interfere with the reliability and validity of the study. However, most studies performed on the subjects of adolescent idiopathic scoliosis are relatively fragile when it comes to validity and reliability. It is also fascinating to observe how different researchers reach their conclusions, and what kind of study design was used to produce the result. The eligibility criterias were specified, and the indications for brace treatment were a progressive curve of 25 ((5 within a year) or more in a child with a skeletal age of less than 16 years for girls, or 17 years for boys. Indications for surgery were defined as a curve that progressed to a 45 angle of Cobb, or more. In 1977, a conventional screening program was introduced, involving annual mandatory screening of all children between 7 and 16 years of age. The study is not randomised, and allocation was not concealed. This means that the assessor knew which group the subjects would be allocated to, which in turn weakens the validity and reliability. There is neither any information about whether the examiners or subjects were blinded to the results, which could significantly influence the outcome of the study. The school health personnel were given a detailed description of how to screen, and a specially trained nurse assisted when the Adams forward bend test was performed. 86 patients were followed for at least two years after the cessation of growth or until an operation had been performed. Logistic regression and odds ratio were used as significance tests. The authors have presented the measurements of all the patients in the study. The risk of deterioration to 45 in children, diagnosed and qualified for treatment before the period of screening was eight times (99 percent confidence interval 1.6-36) greater than after screening (appendix 9, table 7). The authors indicate that early diagnosis is a result of screening, and that initial curve and initial skeletal age are factors related to screening. As the authors expected, there was a lower skeletal age as well as a smaller initial curve in the screening group (appendix 9, table 8). The authors believe that there was still a greater risk (ratio 3.3, P 0.005) of indications for surgery when treatment was started before the screening period, regardless of brace type used. Decisions to introduce screening for scoliosis are partially based on the assumption that early detection of the disease is beneficial. The authors conclude that screening decreases the demand for surgery because the scoliosis is detected at younger age with smaller curves, and therefore having a better prognosis. 7.1.2.3 An evaluation of the Adams forward bend test and the scoliometer in a scoliosis school screening setting. (36) This clinical trial by Grossman et al. was published in the Journal of Pediatric Orthopaedics in 1995. The screening study took place in Florida, USA in the period from 1990 to 1991. The authors wanted to examine the ability of the Adams forward bend test and the scoliometer to detect truncal rotation or asymmetry in a school screening setting. The eligibility criterias are mentioned. However, since this is a school screening, the only inclusion criterion is that the subjects are sixth graders. Both assessors were blinded to each other, and a medical assistant alternated the screening methods in a random fashion. This study is truly randomised since the sixth graders are comparable to any other group of sixth graders. Still, there is no information about who collected and measured the data, which is important regarding the outcome of the study. The study group consisted of 954 sixth graders screened during the school year 1990-1991. Two orthopaedic medical assistants screened all the children independently. Both medical assistants had previously been trained in screening using the Adams forward bend test and trained in the use of the scoliometer. The Adams forward bend test was considered positive if there was any evidence of rotational abnormality (hump). The scoliometer readings were recorded in degrees of angle of trunk rotation (ATR). The authors follow the classification of Bunnel, that a reading of (5( is considered to be abnormal. 678 children (71%) screened normal on both the Adams forward bend test and scoliometer examinations. 48 children (5%) screened abnormal on both visual and scoliometer examinations. 105 children (11%) with abnormal visual examinations were normal by scoliometer. 123 children (13%) with normal visual examinations were abnormal by scoliometer. The authors indicate that the scoliometer and Adams forward bend test actually reflect truncal rotation, and not scoliosis. Their opinion is that the presence or absence of scoliosis on the radiographic examination cannot be used as an absolute criterion for determining the sensitivity or specificity of current methods for detecting truncal rotation. The purpose of this study is to demonstrate that there are a number of children who screen negative on the Adams forward bend test who, when measured by scoliometer, are found to have truncal rotation abnormalities that are considered noteworthy. This result leads the authors to question the underlying principle for the selection of children for scoliometer examination on the strength of a positive Adams forward bend test. It may be that selecting patients for scoliometer examination derived from the Adams forward bend test may raise the risk of the most undesirable medical consequence of school screening, that is, increasing the number of false-negative examinations. The authors advocate that the scoliometer should be used to screen all children and not just those who appear positive on the Adams forward bend test. 7.1.2.4 School screening for scoliosis. (31) This article is a systematic review, written by Morrissy, and was published in Spine magazine in 1999. Morrissy describes the different aspects of screening, and the problems related to the screening process. The advantages with an article like this are all the opinions and theories it discusses, and the fact that the author looks at the problem from many different angles. The author has the possibility to compare recent research with research being performed at much earlier stages, and is also in the position to reveal which articles that provide higher or lower validity and reliability. The author wants with this article to examine the available evidence from school screening as it is currently practiced within the framework of prescriptive screening. Morrissy divides the discussion about screening into five categories: knowledge of the disease, validity and acceptability of the screening tests, diagnosis and treatment, costs, and ethics. To diagnose a scoliosis you require a curvature on a standing radiograph of 11 or more. This can be questioned for being a serious disease, since most cases with small curves (under 30) stay small and do not require treatment. Morrissy imply that it is very difficult to determine when scoliosis becomes a serious problem, and which patients need to be referred for diagnosis and treatment. Today, in almost all screening programs, anyone with clinically observed trunk asymmetry in the Adams forward bend test is considered positive. Despite all research and information gathered about progression of the curves, there are no answers to how to predict what will happen to the individual curve. Today, both the scoliometer and the Adams forward bend test have been accepted as measurement instruments for scoliosis screening. A positive Adams forward bend test shows the amount of rib rotation that causes the asymmetry, but does not always correlate to the amount of scoliosis. Several studies have been trying to estimate the efficiency of the Adams forward bend test. The study of Howell noted that 13% of physiotherapists and 26% of trained nurses failed to visually detect asymmetries in patients who had curves of at least 10(. Williams calculated that if the sensitivity and specificity of the tests used to detect scoliosis were both 90% reliable, something that is not attainable with the current tests, there would for every child who had scoliosis be six patients referred without scoliosis. Morais et al. also tried to estimate the positive predictive value of the Adams forward bend test, and found it to be 42.8% in detecting curves of at least 5, but only 6.4% for identifying curves of (15, showing the inability of the test to discriminate between larger and minor curves. Lonstein reported that 3.4% of all children assessed with the Adams forward bend test were referred, but only 1.2% of those had radiographic evidence of a 5 curve or greater. Scoliometer is another measurement tool used in screening for scoliosis, and was introduced by Bunnel. Murell et al. reported the standard deviation for the measurement of angle of trunk rotation (ATR) in the thoracic spine to be 1.9, and for the lumbar spine to be 2.3 which Cote et al. calculated to give a 95% confidence level of 0 to 5.3 for the thoracic spine and 0 to 6.4 in the lumbar spine. The result they found, showed the sensitivity, specificity, and positive predictive value of the scoliometer to be less than the Adams forward bend test. Bunnel have later changed the original recommendation for referral at 5 ATR to 7 ATR in an attempt to decrease the number of false-positive referrals. This increased cut-off point will increase the number of false negatives, so when 5 rotation is used, only 2% of 20 will be missed, but when 7 rotation is used, 12% of 20 curves will be missed. 13 of 14 orthopaedic surgeons require a radiograph before reaching a diagnosis. Is it possible to know the idiopathic nature of the deformity, and the need for treatment and follow up without a radiograph? The most likely conclusion is that the Adams forward bend test and the scoliometer do not provide sufficient information to avoid the use of radiographs in all patients with physical findings. Another important factor to be mentioned is that the screening and application of treatment should improve the health of the group that is screened. Lonsteins study showed that while fewer patients required surgery towards the end of the study period, this was not accompanied by an increase in the number of children who were braced as would be expected. In the report of Torell there was a matching increase in the number of children braced, but also a fourfold increase in the number of children referred at the end of the study period as compared to the beginning. Goldberg et al. screened 55.484 girls between 10 and 14 years of age over an 11-year period and did not see any alterations in the occurrence of mild or severe scoliosis or in the number of surgery. There are two important factors when considering costs of a screening program. Firstly, not all the patients diagnosed with scoliosis represent cost savings. Some of these patients would not have needed any treatment, some would already require surgery, some would have been diagnosed early enough for brace treatment in the non-appearance of screening, and some would progress to surgery regardless of prescription for brace treatment. Secondly, all the costs must be accounted for, and not only the direct costs which most studies report. These are costs like seminars to train volunteers, mailing to parents, and salaries for paid personnel. Screening is not a process without the possibility of harm, and there are two critical issues in any screening program. There must be enough knowledge about the disease to tolerate cut-off criterias for the screening tests, and suitable application of treatment only to those who need it. Secondly, the test must be validated before it is applicable to large populations. The low prevalence of scoliosis will always lead to a high number of false positives in a screening program. It is believed to be, in the highest target group, between 2% and 4%. It is recognised that there is a large difference in the natural history of scoliosis progression between boys and girls. A study by Morais et al. found that the prevalence of idiopathic scoliosis of 10 or greater was 23.7/1000 for girls and 11.4/1000 for boys, giving an overall prevalence of 17.6/1000. Prevalence of scoliosis of 25 or more is 3.1/1000 for girls and 0.4/1000 for boys. Mass screenings of boys is a practice, which have been discussed before. The low prevalence of scoliosis is one factor in increasing the efficacy of screening procedures. Another would be to increase the sensitivity and specificity of the measurement instruments. Morrissy also suggests that there would be an idea to increase the cut-off from 5 to 7 or even higher. A few curves will be missed, but Morrissy reveal that the overall benefit to the population could be improved by the decreased diagnosis and treatment of those who will not benefit from the screening procedure. Morrissy points out that screening have benefited many children through early detection and management, and the programs have also provided us with knowledge and information about this not known disease. Still, evidence strongly suggests that changes must be done in the present screening program. 7.1.2.5 The efficacy of school screening for scoliosis. (30) This review article was written by Karachalios et al. and was published in the Orthopedics magazine in April 2000. The article questions different aspects of screening, and the authors try to clarify some theories about adolescent idiopathic scoliosis. This article is included because it is very informative to compare it with the review of Morrissy, and to consider the references used. It was very difficult to judge the validity and reliability of the two reviews, but in the article by Karachalios a lot of the information is based on the experience of the author, and not on previous trials. The authors have not performed any controlled trials, but refer to cases of adolescent idiopathic scoliosis they have worked with. Karachalios et al. may be very experienced when it comes to adolescent idiopathic scoliosis, still, as long as no controlled trial has been performed, there may be room for lack of validity and reliability. The authors believe that it is necessary with a critical review of the screening procedure after it was introduced more than 40 years ago. Karachalios et al. distinguishes between two forms of scoliosis; one that will progress to a significant degree, and the other that will remain minor and cause somewhat small complications. A curve of (30 will rarely be a significant health problem, and only curves of >30 would be a serious health problem for the individual. The authors state that the prevalence of scoliosis varies from 1% to 21% based on the different criteria used for detection and diagnosis. The early school screening programs detected a prevalence between 5% and 15%, but after idiopathic scoliosis was given a definition, the published prevalence of idiopathic scoliosis had drastically decreased. With the use of strict radiographic criteria for >10 curves, these numbers have decreased to 0.4%. The authors point out that because of the low prevalence there will always be a certain numbers of false-positives, and that this low incidence invalidates the screening methodology and appropriateness of the circumstances for a scoliosis school screening program can be criticised. Since most of the minor curves are not serious, it is much more important to ask how many of the <20 of Cobb angle are due to progress. In a 10 year follow up of the material on the subject, the authors found that of curvatures with an initial Cobb angle of <10, only 35.8% progressed with an increase ranging between 5-10, while a decrease of the Cobb angle was observed in 14.9%. In the curvatures with an initial Cobb angle between 10 and 20, 48.3% progressed with an increase ranged between 5 and 14, while a decrease of the Cobb angle was observed in 6.9% of these curves. In the same material they found that bracing treated 0.15% of the curves, and only 0.03% required surgery. The authors also refer to another study where children were referred to hospitals after screening, only 0.04% needed bracing and 0.004% needed surgery. The traditional methods to measure scoliosis worldwide are the Adams forward bend test, the scoliometer, Moir topography, and the measurement of rib hump. Even though radiographs surely reveal spinal deformities, its use as a screening test for school screening is not ethical, because of the hazard and the cost it would produce. According to the experience of the person behind the article for scoliosis cases (>10 Cobb angle), the Adams forward bend test showed a number of false-negative results with sensitivity of 84.37% and specificity of 93.44%. The sensitivity of the Moir topography, the humpometer, and the scoliometer proved to be 100%, 93.75%, and 90.62% respectively, whereas specificity was 85.38%, 78.11%, and 79.76%, respectively. The authors found that the Moir topography had the highest sensitivity and negative predictive values in screening for scoliotic curvatures with no false-negative results. The authors want to reveal that it is important to state that the Adams forward bend test showed low sensitivity and negative predictive values and a low number of false-negatives. It is reported that the drawback for using the Moir topography is its high number of false-positives. The authors found much lower false-positive results due to recognition of the problem (14.44% for Moir topography, 21.62% for humpographs, and 20% for scoliometer). The logic of school screening should be that early non-operative management of scoliosis is an effective way to arrest a progressive spine, thereby avoiding the need for surgery. Clinically efficacy of the non-operative treatments likes bracing, electrical stimulation, and exercises, have not been demonstrated in randomised controlled trials. Miller et al. and Goldberg et al. did not find any statistical difference in the curvature progression in children who were fitted with braces and in children who received no treatment. Still, in a recent study Nachemson et al. found that bracing was effective in arresting curvature progression. The authors state that if the early detection and non-operative treatment have not shown to be effective in preventing the progression of the curvature and in reducing number of spinal surgeries, the point of screening programs is lost. The authors believe that school screening must be challenged for the following reasons: 1) progressive spinal curvatures requiring aggressive treatment are rare, 2) the Adams forward bend test is unsafe and not reliable, 3) the over-referral for diagnosis and observation of children that have minor abnormalities, and 4) that the natural cause of scoliosis, and the effectiveness of the conservative treatment, is not understood. Treatment Some articles mention active exercises as a treatment form alone or in combination with a brace, but there are no hard fact or evidence found in any of these articles that this treatment halts the progression or even improves the curve in adolescent idiopathic scoliosis. Neither did any of these articles support their findings in a proper clinical trial fashion. The articles were analysed using the Pedro-scale to assess the methodological quality of the studies (table 4). Assessing the articles with the Pedro-scale proved to be difficult when the articles leave out many of the research-terms use in the Pedro-scale. Few of the studies were blinded, and if so it is not mentioned if it is the patient, the tester or both. Not all of the articles included in the result section have a control group. In the discussion chapter, missing links concerning validity and reliability in the articles are included. The articles get a low score on the Pedro-scale because a lot of significant research data are not included. Still these were the best articles examined by the project group and therefore included as results. Table 4: Outcome Pedro-scale; treatment. Pedro-scale, treatment.1.2.3.4.5.6.7. 1.Eligibility criteria were specified.YesYesYesYesYesNoYes 2.Subjects were randomly allocated to groups.Yes*NM*NM*NMYesNoNo 3.Allocation was concealed.*NMYesYesYes*NMNoNo 4.The groups were similar at base line regarding the most important prognostic indicators.*NM*NM*NM*NM*NMNoYes 5.There was blinding of all subjects.*NM*NMYes*NM*NMNoNo 6.There was blinding of all therapists who administered the therapy. *NM*NMYes*NM*NMNoNo 7.There was blinding of all assessors who measured at least one key outcome.*NMYesNo*NM*NMNoNo 8.Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups.YesYesYesYesYesYesYes 9.All subjects for whom outcome measure were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by intention to treat.YesYesNoYesYesNoYes10.The results of between-group statistical comparisons are reported for at least one key outcome.YesYesNoYesYesYesYes11.The study provides both point measures and measures of variability for at least one key outcome.YesYesYesYes*NMYesNo*NM= Not Mentioned. The following section is an overview of the results of the data extraction for the articles concerning screening of adolescent idiopathic scoliosis. In addition a summary of each article will be presented. 7.1.3.1 Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. (61) Authors of this study were Alf L. Nachemson and Lars-Erik Peterson. It was written in Gothenburg, Sweden in 1995 and edited in the Journal of Bone and Joint Surgery. A multi-center prospective trial was designed, and a controlled clinical trial was established in a well-defined group of patients with adolescent idiopathic scoliosis. Each participating center adhered to its own preferred method of treatment. This method was recommended as a better alternative to randomisation. The study is relatively large, and treatment of scoliosis is controlled between many centres. There may be biases of the different performances of treatment and recording of results, that is, the inter-reliability might be low. This was the most thoroughly described clinical trial reviewed, and was included for this reason. The Scoliosis Research Society (SRS) initiated a controlled clinical trial in 1985 to investigate the effectiveness of bracing as a treatment for scoliosis. Many previous studies of full time bracing showed that braces arrest about 80% of curves. All of these studies, however, were uncontrolled which means there were no simultaneous groups of untreated, un-braced patients for comparison. Therefore, there was some doubt that brace treatment of scoliosis was effective, and it was proposed that bracing may be no different than natural history or what happens when no treatment is undertaken. Patients of the same age, curve pattern and curve severity were divided into two groups, one treated with bracing, and one not treated. As reported in a 1993 issue of the Spinal Connection, the result of this study demonstrated, with statistical certainty that bracing is effective compared to natural history (61). 286 girls with adolescent idiopathic scoliosis were studied. Of them 129 patients were just observed, 111 patients treated with an underarm plastic brace, and 46 patients treated with nighttime electrical surface stimulation. 39 patients were lost to follow-up, which is a great percentage of the patient group. This affects the outcome of the study negatively. The end point of failure of treatment was defined as an increase of the scoliotic curve of at least 6. Treatment with a brace was associated with a success rate of 74 % at four years, observation only, with a success rate of 34%, and electrical stimulation with a success rate of 33%. The patients were expected to wear the brace for at least 16 of 24 hours a day. Treatment with a brace prevented progression of the curve of 6 or more until the patients were 16 years or older, and this effect was significant (p<0.0001) (61). 7.1.3.2 A meta-analysis of the efficacy of non-operative treatments of idiopathic scoliosis. (51) In 1997 Rowe et al. conducted a meta-analysis that was published in the Journal of Bone and Joint Surgery. 20 studies were investigated in the USA on the efficacy of non-operative treatment for idiopathic scoliosis. This is a large research performed. The method is not described in a proper way, but as the previous article, it is promoting bracing as an effective treatment form for adolescent idiopathic scoliosis. The explanations on the method of the different studies are left out, and the meta-analysis cannot evaluate the reliability of these. These studies found that brace treatment is of value. The use of the Milwaukee brace or other thoracolumbosacral orthosis for 23 hours per day effectively prevented progression of the curve. Bracing for 8 or 16 hours per day was found to be significantly less effective. 1910 patients, of them 1459 brace treated, 322 treated with lateral electrical surface stimulation, and 129 with observation only. The mean proportion of success was 39% for lateral electrical surface stimulation, 49% for observation only, 60% for bracing 8 hours per day (Charleston bending brace), 62% for bracing 16 hours per day, and 93% for bracing 23 hours per day. The highest proportion of success was 99%, achieved by the Milwaukee brace (p<0.0001) (51). Progression of the curves was measured with the use of the Cobb method in all studies. The level of maturity had a significant effect on progression of the curve. Curves were generally less likely to progress as the level of maturity increased. The studies of mature adolescents had a significantly better outcome than those of mixed, immature adolescents, and juvenile groups (51). Curves of less than 30 degrees rarely progress after maturity, but larger curves may continue to increase throughout the life of the patient. Although bracing has long been the mainstay of conservative treatment of scoliosis, its efficacy has not been demonstrated definitively in prospective or randomised clinical studies in which it has been compared with other forms of non-operative treatment. In 1984, Miller et al. retrospectively compared bracing with observation for the treatment of mild adolescent idiopathic scoliosis. They noted a systematic but non-significant trend in favour of bracing, but the curve failed to progress more than 5 in 80% of the 225 patients in both groups. These study results go with the trend of restrictive bracing for fewer hours each day (51). 7.1.3.3 Adolescent idiopathic scoliosis. The effect of brace treatment on the incidence of surgery. (62) In 2001, Goldberg et al. conducted a retrospective analysis, in the USA. This article was published in the Spine Journal. It compares the patients treated with a brace with the incidents of patients undergoing surgery after brace treatment to analyse the effectiveness of brace wearing. This recent analysis shows the effectiveness of bracing in a different light. Brace treatment was set to focus on the incident of surgery. They found that there was no difference in the proportions undergoing surgery from those wearing a brace with Cobb angles less than 50 at diagnosis. However, in a group of patients with Cobb angles between 50 and 59 a significant greater proportion from the un-braced group underwent surgery. This would indicate that only at Cobb angles where bracing has generally been considered to be less effective it has its main effect. 153 patients with adolescent idiopathic scoliosis were included (11 boys and 142 girls). They had reached the age of 15 years by the time they were last reviewed. The mean curve at diagnosis was 32.95. 61% had major thoracic curves, 31% thoracolumbar, 6.25% lumbar, and 1% double major. 30.8% of the thoracic curves have been operated, 43.3% of the thoracolumbar, and 16% of the lumbar. In total 43 (28.1%) of whom 6 were boys, were operated (62). This study does not distinguish patients by curve pattern, gender, or maturity but simply looks at overall incidence of surgery. For the centre where the patients were evaluated, surgery was not always considered as a last option. 7.1.3.4 Adolescent idiopathic scoliosis: Treatment with the Wilmington brace. (63) This study review by Allington and Bowen from 1996 was written in the USA, and published in the Journal of Bone and Joint Surgery. It compares the effectiveness of full-time and part-time use of the Wilmington brace in the treatment of adolescent idiopathic scoliosis with curves < 40. The research was performed using a Chi-square analysis and a one-way analysis of variance to evaluate the influence of the magnitude of the curve. It showed that both full-time and part-time bracing had significantly more effect compared with electrical stimulation. But the difference in progression of the scoliotic curve (measured with the Cobb method) between the groups that had part-time and full-time bracing was not significant. The patients were divided into two groups on the basis of the magnitude of the scoliotic curve. This grouping makes it hard to compare it with other studies. Of 88 patients who had a curve of <30, 36 had full-time bracing, 32 had part-time bracing, and 20 had electrical stimulation. Of 100 patients with curves of 30 to 40, 62 had full-time bracing, 17 had part-time bracing, and 21 had electrical stimulation. Chi-square analysis was used to assess the significance of gender and the degree of skeletal maturity. A one-way analysis of variance was used to evaluate the influence of the magnitude of the curve. Of the patients with curves of less than 30, 69 patients had a single curve (33 thoracic, 24 thoracolumbar, 12 lumbar), and 19 had double major curves (8 thoracic-thoracolumbar, 11 thoracolumbar). The patients with a curve between 30 and 40 included 60 single curves (40 thoracic, 15 thoracolumbar, 5 lumbar), 39 double major curves (23 thoracic-thoracolumbar, 16 thoracolumbar), and one multiple curve. Patients in the full-time program wore the brace 23 of 24 hours a day. Weaning took a mean of one year. It began when the girls had a Risser sign of 4 and were two years post-menarche, and when the boys had a Risser sign of 5. Part-time bracing consisted of wearing the brace 12 to 16 hours a day until maturity. The electrical stimulation was applied with a single or dual-photon electro-spinal orthosis that was worn at night. Emans have suggested that part-time bracing may be as effective as full-time bracing (63). 7.1.3.5 Effect of exercise, bracing and electrical surface stimulation on idiopathic scoliosis: a preliminary study. (53) El-Sayyad and Conine released research material in 1994 about the effect of exercise, bracing, and electrical surface stimulation in patients with idiopathic scoliosis. This research was carried out in Saudi-Arabia over only 3 months. Effect of exercises alone and in combination with electrical surface stimulation or bracing was compared to see what gave the best results. The study had a lack of method description. A group of 30 children with progressive idiopathic scoliosis were randomly assigned to a 3 months program. Inclusion criterias were that the patients with idiopathic scoliosis had to be between 6 and 16 years old, have a scoliotic curve between 15 and 45 and have no other orthopaedic, neurological or medical condition. Groups receiving exercise treatment, exercises and bracing, or exercises and electrical stimulation were compared. Bracing was a minimum of 18 hours each day with the Milwaukee brace. A decrease of 2 to 4 post-treatment was noted for all groups with greatest improvement observed with bracing. The beneficial superiority of the effect of bracing or electrical stimulation over exercise could not be statistically supported. The interactions between exercises and exercises and bracing were not significant. 7.1.3.6 Influence of an in-patient exercise program on scoliotic curve. (42) This article was informative to promote the Schroth method as an exercise treatment form for adolescent idiopathic scoliosis. It is written by Weiss in 1992, who works with the Schroth program in Bad Sobernheim, Germany. This article is a review article, but is included here because it evaluates active exercise as a treatment form, and it gave a short description of some results from the Schroth program. This article scores low on the Pedro-scale because it contains only a summary of the outcomes of the treatment and is not a clinical trial. On 107 idiopathic scoliosis patients treated with the Schroth method from the years 1981 to 1989 it is shown on radiographs that the treatment with active exercises have been of great benefit. Average angle of curvature measured with the Cobb technique before treatment was 43,06, and after treatment 38,96 (42). In another result from the treatment with the Schroth method, 217 patients who had not reached skeletal maturity, and who had an average Cobb angle of 31, had follow-up elsewhere for an average of 31.5 months after being treated at the Katharina Hospital. 118 of these patients did not use a brace. 16.1% had curve progression, 15.2 % had an improvement of the Cobb angle by more than 5, while 68.7% remained stable (42). 7.1.3.7 Treatment of idiopathic scoliosis with side-shift therapy: an initial comparison with a brace treatment historical cohort. (64) Boer et al. wrote this article in Holland in 1999, and the study was conducted at Sint Maartenskliniek in Nijmegen. The article was published in European spine journal. The article describes a historical retrospective study of an initial comparison between treatment with side-shift therapy and brace (64). Due to the type of study, this article would initially have been excluded after completing the data extraction. Based on the fact that there is a very limited amount of studies describing the effect of active exercise and side-shift therapy, this study was included in the project although it is considered being a weak study due to its relatively low validity. This fact has been taken into consideration when interpreting and discussing the findings of this study. The study was assessed for its methodological quality on basis of several criterias. For this the Pedro scale was used. The study clearly mentions eligibility criterias. To be included as a subject in the study the patient with an idiopathic scoliosis had to be between ten and fifteen years of age. This age limit was chosen because the patient had to be able to learn the shifting movements and to perform them independently after the training session was complete. This age group was also chosen because the patient had to still be in the growth period. The patients had to have a Cobb angle between 20 and 32 degrees. The only treatment method was the side-shift therapy, and the treatment duration was set to at least four months. From 1985 to 1995, 91 patients followed the side-shift therapy at Sint Maartenskliniek, and after applying the inclusion criterias, 44 patients (2 male and 42 female, mean age 13.6 years) were selected as subjects in this study. The control or historical reference group consisted of consecutively braced patients with idiopathic scoliosis that had received brace treatment from 1970 to 1982. After applying the inclusion criterias, 120 patients (13 male and 107 female, mean age 13.6 years) were selected as subjects in this study. The two groups were similar on baseline regarding the most important prognostic indicators like age and Cobb angle at start of treatment, and length of treatment they were given. The objective with this study was to ascertain whether side-shift therapy was as successful as brace treatment in preventing progression of the primary scoliotic curve. It serves as an investigation comparing the efficacy (non-compliant cases removed) and efficiency (intention to treat) of side-shift therapy with brace treatment. The side-shift and the brace groups were compared using two measures for treatment outcome. By using an odds ratio, the association between the type of treatment and the success and failures were tested. A confidence interval of 95% was used. The second outcome measure was the progression of the Cobb angle between the start and the end of the treatment. For this an analysis of variance was used. A radiograph was made in the shift position, and the Cobb angle was measured. Failure was defined as non-compliance, an increase of Cobb angle greater than 5( within four months, an increase of Cobb angle greater than 10( during the total treatment period, or a Cobb angle greater than 35(. Ten patients were considered as a side-shift failure, and for these patients brace treatment was started. The patients received side-shift instructions from a physiotherapist at Sint Maartenskliniek. All the patients in the side-shift group had 10 to 12 half-hour sessions once a week. When they showed proficiency in the side-shift method, they received a refresher session once every 4 months. The results from this study indicate that there was no significant difference for the chance of success between the side-shift and the reference brace treatment groups whether tested for efficiency or efficacy. The difference between the groups concerning the mean progression of Cobb angle was small and not significant. The conclusion from this study is that the less taxing side-shift therapy should be considered as a possible additional treatment for adolescent idiopathic scoliosis with an initial Cobb angle between 20 and 32 degrees (64). 8.1 Discussion and conclusion 8.1.1 Introduction Recent research has contributed to a better understanding of adolescent idiopathic scoliosis. However, the best possible strategy for screening, diagnosing, and treating this common spinal deformity remains controversial. There exists several different treatment alternatives, but neither has scientifically succeeded to overcome all the diverse opinions about the subject. Active exercises are one of the possible treatments to arrest the progression of a curve, but it has been seriously challenged as a treatment alternative. Another discussed topic is the relevancy of screening in detecting adolescent idiopathic scoliosis as early as possible. The search after relevant information about the two topics provided the project group with limited amount of information. The number of articles and relevant literature turned out to be less than first imagined, and only a few articles related to active exercises and adolescent idiopathic scoliosis was found. Randomised trials were rare, and other important factors securing validity and reliability of studies completed were often inadequate. The issues that will be discussed below are if active exercises and bracing have an effect in preventing progression of a scoliotic curve. In addition, interventions for detecting an adolescent idiopathic scoliosis will be focused on. 8.1.2 Screening In many countries, screening has been introduced as an attempt to detect adolescent idiopathic scoliosis as early as possible. The literature reports varied and disagreeing views about the efficacy and efficiency of mass screenings. The problem of greatest economic significance for scoliosis screening programs is the relatively large number of children screened positive who ultimately prove to be normal or to have insignificant curves. The rationale behind screening is the assumption that early detection of curves permits initiation of conservative therapeutic measures that may prevent progression of the curves and thereby avoid the complications of advanced scoliosis. The Cobb method of radiographic measurement is a measurement tool of the scoliotic curve, and is used as a golden standard procedure to diagnose and follow the progression of scoliosis. However, young patients can be exposed to a significant amount of diagnostic radiation by using this method, and several studies have demonstrated that the use of multiple full-spine radiographs results in a small, but significant increase in the incidence of cancer in the adolescent idiopathic scoliosis population (37). To get a better understanding of the problems within the screening process one must take all the aspects into account. Feasibility of screening procedures, diagnosis and treatment, costs, and assessment are all subjects needed to be taken into consideration. The best method of assessing patients for scoliosis has been debated. The most commonly performed test in school screening is the Adams forward bend test, yet its effectiveness has been questioned. The degree of rotatory asymmetry in the Adams forward bend test can be measured with a scoliometer. Still, the sensitivity and specificity of the scoliometer is unclear. In the study by Cte et al. (37) the authors assessed 105 patients to investigate the reliability and diagnostic accuracy of the scoliometer and the Adams forward bend test. The authors were of the opinion, that the scoliometer should be at least 90% sensitive in detecting curves measuring 20 or more. In the thoracic spine, the crude sensitivity of the scoliometer was only 71%, compared to 92% of the Adams forward bend test. Cte et al. concluded that the Adams forward bend test and the full-spine radiograph remained the better choice in detecting idiopathic scoliosis (37,60). The study by Cte et al. is not a controlled randomised clinical trial, however compared to other clinical trials it has managed to become somewhat reliable. Other authors have come to other conclusions regarding screening, and it is very difficult to compare the different clinical trials, and drawing a conclusion. According to Karachalios et al. (36) the Adams forward bend test showed a lot of false-negatives, with a sensitivity of 84.37% and a specificity of 93.44%, compared to the scoliometer that could show a sensitivity of 90.62%. This study could be criticised for leaving out important information, like how many patients that were assessed and the method used to receive these data. Grossman et al. (36) measured 954 schoolchildren for idiopathic scoliosis with both scoliometer and Adams forward bend test, and discovered that 11% with abnormal Adams forward bend test were normal with scoliometer, and that 13% abnormal by scoliometer were normal by Adams forward bend test. Grossman et al. points out that these tests actually measures trunk rotation and not scoliosis, and that scoliometer should be used together with the Adams forward bend tests, since it can detect small curves not seen in this test. There are numerous reports about data regarding screening and the instruments used in the examination. A valid estimation of the incidence of false-positives and false-negatives in a screening setting is difficult to predict, since there must be a confirmation by a radiograph of all subjects tested to know whether the measurement-tools are able to provide the necessary information. The project group has not heard of such study. It would be advantageous if there existed a screening protocol, which would give all therapists clear information on how an assessment should be carried out. Based on this conflicting information there is no reason why not both the Adams forward bend test and the scoliometer should be combined in a screening program, since none of the instruments rule out the other. Still, the Adams forward bend test and the scoliometer do not provide sufficient reliable information to replace the use of radiographs in patients with these physical findings. The logic of screening should be that the screening tests are accurate and reliable in detecting curves, that early detection of curves result in improved health outcomes, and that effective treatment modalities are available for cases detected through screening. Goldberg et al. screened 55.484 girls over an eleven years period and did not see any change in the prevalence of mild or severe scoliosis, not even in the number requiring surgery (36,60). In the study of Lonstein, fewer patients required surgery in the study period, but this was not accompanied by an increase in the numbers of children who were braced (60). Montgomery and Wilner found that after screening there was a decrease of 45% in the demand for surgery compared to before screening. The fact that only two groups of 45 subjects took part in this study at two separate intervals may alter the validity and reliability of the study. The authors also claim that even though treatment was initiated before the screening started, there would still be a greater risk of indications for surgery. This could be discussed since it is not unlikely that some of the children referred for treatment could have been identified by their family doctor or on an unplanned visit to the school nurse. Karachalios refers to a couple of studies (36), which produced positive results of screening to arrest progressive curves, however these articles are old and have been criticised by other researchers. Karachalios states that the reason for screening programs are lost if there is no evidence of them reducing the number of spinal surgeries. After comparing the information and research material about the effect of screening in relation to treatment, it is difficult to draw a conclusion whether it is preventive or not. Large studies, like the one of Goldberg et al., indicate that screening has not produced a significant outcome, and that more controlled trials are needed to prove its value. The cost of a screening program is also difficult to predict. Many people are of the opinion that money is not a subject when it comes to preventing a child suffering from a serious disease. Still, one has to be realistic, and money spent in one area of health care will be unavailable in another area, which could have had a greater impact on the population. Morrissy state that there are two important factors considering the costs of a screening program. First, not all patients diagnosed with scoliosis represent savings. Some patients would not need treatment, some would require surgery no matter what, some would have been diagnosed early enough for bracing even without screening, and some would need surgery regardless of brace treatment. Second, all costs must be included. The direct costs from the screening process itself are mentioned in most studies and reports about screening. The indirect costs, however, like those from the referring process, diagnosis, follow-up, and from the radiographs are often left out. The excessive numbers of false-positives for diagnosis markedly increases the total costs without improving the medical benefits. The discussion could go on, because at this point there is difficult to find all the direct and indirect costs which would be necessary for a cost benefit analysis of screening, and no one seem to agree what should be included in such a analysis. Scoliosis screening has benefited many children through early detection and treatment, and a lot of current knowledge about scoliosis has come from these programs. However, scoliosis-screening needs to be challenged in a number of areas, and changes need to be made in the way scoliosis is screened for. Those involved in school screening programs as well as those advocating and supporting such programs need to develop and fund new approaches if such programs are to remain of value to the public. It is of great importance that no new approaches should be recommended without validation of the methods and some proof of the benefits. 8.1.3 Treatment A lot of new devices, training techniques, and equipment are being created to find an effective and reasonably compliant way for the patient to be treated for the adolescent idiopathic scoliosis. Most recent equipment is in the experimenting phase, some are well known and recognised, but again rejected by others. Many therapists support the use of exercises for the treatment of adolescent idiopathic scoliosis. Although physical exercise in general can be of value to a lot of scoliotic patients the specific corrective exercises may not be beneficial. The most frequently used method of non-operative management of adolescent idiopathic scoliosis is bracing. According to Nachemson et al. bracing is the most successful non-operative treatment alternative in relation to prevention of progression in degrees of the scoliotic curve (61). However, despite the widespread use of orthotics in the management of adolescent idiopathic scoliosis there has been few randomised controlled prospective clinical studies on brace treatment of adolescent idiopathic scoliosis. Researchers find it difficult to agree on the subject, since most studies have different settings, criterias, and populations. Still, it is imperative that knowledge is gained about the natural history of adolescent idiopathic scoliosis in order to learn about additional factors in curve progression that will allow more selective indications for orthotic treatment. The range of measurement error associated with the Cobb method is ( 5 degrees, which means the probability of miss-classifying a successful treatment as a failure or a failed treatment as a success may be quite high. The patients positions when measuring the Cobb angle also seem to be of significant importance. A marked difference between the angle when standing and supine has been shown. When standing the angle could be 30, but there is often 10 or less showing in the lateral bending position or lying supine (47). When the Cobb angle is measured in different positions, this can cause different outcomes between patients in the same or different studies. Since the Cobb measurement is said to be unreliable, the difference in degrees of curvature can be even more significant from patient to patient. The value of treatment forms such as bracing can be misinterpreted from these results. Poor matching groups will have a lot to say for the outcome of a study. A thoracic deformity group compared with a thoracolumbar deformity or lumbar deformity group will give less significant results since the prognoses for thoracic curves are known to be much worse than the thoracolumbar or lumbar curves (47). When these groups are measured against each other in a study, the researchers can manipulate the results to what they think is the best. If the researchers want bracing to give a great effect, they can only observe the thoracic deformity group, while treating the lumbar deformity group with braces. This may not be done deliberately, but it makes a big difference if the reader does not analyse the results thoroughly. The length in time of treatment and the follow-up of the study is significant for the result. A study comparing the use of full-time bracing and part-time bracing (wearing the Wilmington brace) gave results with no significant difference in prevention of the scoliotic curve. Emans have suggested that part-time bracing may be as effective as full-time bracing (63). Long time use with exercises and bracing has proven to be more effective than short-term treatment (51,61). Most of the articles assessed have shown that bracing for 23 hours per day gives a better result than bracing for 8 to 16 hours per day. However, many studies do not have the possibility to control the patient for the compliance of the brace use. The patient can say he has worn the brace for the specified amount of hours each day, but this is not always true. Some braces give greater compliance than others, and this will naturally affect the time the brace is worn and thus the results for the patient (13,47,48). Large studies have the tendency to give biases because of the large quantity of patients measured. They often average the results, and when this happens a good result can be cancelled out by a bad result. If two patients with idiopathic scoliotic curves of 30 are treated with a brace and compared, and one of them may progress to 40, the result is negative. If the other patient improves with 10, the average of these patients will result in an idiopathic scoliosis of 30, which is a good result taken into consideration that bracing is meant to halt the progression of the scoliotic curve and not necessarily improve it. The overall view of the study will then be that bracing had a positive effect on idiopathic scoliosis, even though there was progression of the curve in 50% of the cases (48). With regards to treatment with electrical stimulation Rowe et al. mentioned lateral electrical surface stimulation as a method no longer in use. Though this may vary from therapist to therapist, electrical stimulation has surely failed to give good results as a treatment alone for idiopathic scoliosis and is to compare on the level with observation only (51,61,63). It is more often considered as a supplement to brace therapy and exercises (53). The article Effect of exercise, bracing and electrical surface stimulation on idiopathic scoliosis: a preliminary study is weak in the total sense of a research perspective. Its method was poorly described, and the treatment-period is questionable considering that bracing might get its effect over a longer period of time than electrical stimulation. This article is evaluated because it was the only clinical trial found including exercise as a treatment form. As an alternative to bracing, Eckerson and Axelgaard suggested that electric surface stimulation be used for curves measuring between 20 and 45 degrees (53). The indications for electrical stimulation is said to be similar to those of bracing, but according to Lonstein and Winter, candidates with curves above 40, are not recommended for this treatment. The electrical stimulation is to be worn only at night and has no weaning period (48). The Schroth exercise regime is used in Germany and many other countries in Europe. It has shown many good results up through the years since its start. Still, there is a lack of evidence-based material from clinical trials to classify it as a treatment form on the level with bracing. Even though specific exercises have not directly proven to prevent progression of a curve, exercises in general always have a positive effect on people. Exercises have a good effect on the trunk muscles while wearing the brace, and the muscle tone in the rest of the body is kept at a normal level by performing regular exercises. Interpretation of the information gathered indicates that active exercises in combination with bracing are of advantage to the patient with adolescent idiopathic scoliosis (42). The therapies for idiopathic scoliosis are all symptomatic, and the goal of the treatment is to inhibit further progression by correction of the curve. Brace therapy is considered a passive form of therapy. When applying side-shift therapy, the spine will be actively corrected by the patients own muscle contractions (64). It is difficult to assess whether side-shift therapy influences the natural history of the scoliotic curve in a positive way (64). The data from this study is insufficient to determine this effect. This study limited side-shift therapy to patients with initial Cobb angles less than 32 degrees, because the effectiveness of the therapy has not yet been fully documented (64). It would perhaps have been easier to detect the influence of the side-shift treatment if they had chosen patients with Cobb angles above 32 degrees, since the risk of progression is more pronounced in larger angles. A prospective study that compares side-shift therapy to treatment only by observation is needed to investigate the influence of side-shift therapy on the natural history (64). Due to the fact that a lot still remains unclear concerning the effect of side-shift therapy, a randomised controlled clinical trial with higher validity would be advantageous. Because of the ethical considerations related to not giving adolescents with idiopathic scoliosis treatment, it is difficult to investigate the effect of a certain treatment method compared to only observation. Clinical trials on a large number of subjects provide more precise estimates of the size of treatment effects than trials on a small number of subjects (59). The amount of adolescents with idiopathic scoliosis is too limited to carry out a valid and reliable study with a subject group representing the general population. Dropouts always introduce uncertainty into the validity of a study (59). Due to the fact of being a historical retrospective study, there were no dropouts from the side-shift therapy or the brace treatment group. This strengthens the validity of the study, but due to not being randomised nor blinded, it is considered as a study with a relatively low validity. With no dropouts it was also possible to measure the outcomes on all the patients initially allocated to the groups. The study reports results of between-group statistical comparison. The groups were similar at baseline regarding the most important prognostic indicators. All together this strengthens the methodological quality of the study. The authors themselves mention two methodological considerations that could have influenced the findings. A systematic measurement error could contribute to the results found. Observer bias refers to the possibility that the investigators belief in the effectiveness of a treatment may subconsciously distort the measurement of the treatment outcome (59). In this study, different investigators measured each treatment group, and this may lead to an observer bias in addition to the fact that systematic measurement errors could occur. By blinding the observer or investigator, this bias can be excluded, and the validity of the study increases. It was also difficult to assess the compliance for both treatments. Not wearing the brace would have been easier to judge than whether the patient remembered to side-shift while doing homework or watching television. It is also not known how much shifting is necessary to be beneficial. Due to the fact that 42 of the 44 adolescents receiving side-shift therapy, and 107 of the 120 adolescents receiving brace treatment, were girls, the compliance in this study may be higher than normal. Adolescent girls are often more aware of their body image and wish to improve it, and this may have contributed to a higher compliance. This should be taken into consideration when applying the results of the study to the general population because compliance is paramount to the success of almost any treatment. In conclusion, the low validity is attributed to the fact that this study had no randomisation and no real control group that did not receive any treatment. This study does not mention any statistical tests used to increase the reliability. It is only known that two different investigators measured the treatment groups, but not how many times each subject was measured. The fact that this was a historical study also implies that there are no possibilities to check these measurements. This reduces the reliability of the study. A low reliability may reduce the chances of finding true significant differences between the measurements, and this could be the case in this side-shift study. Therefore it remains controversial whether side-shift therapy can contribute to prevention of progression of curves in adolescent idiopathic scoliosis. Information about the role of the physiotherapist in the treatment of patients with adolescent idiopathic scoliosis is very restricted. The physiotherapist is usually involved in postoperative training, and is also the advisor in a brace treatment process. There are a couple of treatment alternatives for adolescent idiopathic scoliosis where the physiotherapist is directly treating the scoliosis, like the side-shift treatment and the Schroth-techniques. These treatment alternatives focus on biofeedback and body awareness, where the job of the physiotherapist would be to correct posture and motivate the patient. Before the work of the physiotherapist is further evaluated by other health instances, knowledge about the natural history of adolescent idiopathic scoliosis and effect of screening must be enhanced. There are many things that should be taken into consideration when doing a good research to find an effective and compliant way of treating a patient with adolescent idiopathic scoliosis. First one has to find a treatment method, and then perform the treatment. In the case of adolescent idiopathic scoliosis, the treatment period will last for years to be able to get a sufficient result. However, because of the ethical difficulties involved in the implementation of such a study in a large scoliosis clinic that serves young, sensitive adolescents and their concerned parents, many physicians are reluctant to participate. Patients are followed, managed and treated by different physicians and different forms of results will naturally occur. Patients, which are left in the observation group, will of course not get any treatment and one can always raise ethical questions about this. There must be adequate measuring tools used or else a lot of the information recorded will be viewed as invalid. Validity implies that a measurement is relatively free from error. A valid test is therefore also a reliable test (59). But an invalid test can also be reliable. Reliability refers to the fact that a measurement is consistent and free from error (59). To be able to scientifically describe the outcome of a certain treatment method it is crucial to have a control group. The control group and the treatment group have to be the same in every respect that determines the outcome. Only then can one be sure that the result and effect is to be attributed to the treatment and not to any external factors. When subjects are randomly allocated to groups, differences between treatment and control groups can only be due to treatment or chance. This is the only way to ensure the comparability of treatment and control groups (59). According to the Scoliosis Research Society: a well-designed study must include a large cohort of similar patients who have similar patterns of deformity and similar degree of curvature. All patients should be followed from the time of inclusion in the study at least until skeletal maturity. Such a cohort of patients should then be randomised to different sorts of treatment, and the result should be evaluated in relation to a predefined end point (at least to skeletal maturity) (47,61). Ideally, the effectiveness of a brace in the treatment of adolescent idiopathic scoliosis should be studied with a prospective, randomised trial. Until the aetiology of scoliosis and its full natural history are understood, brace treatment programs and other treatment programs in general, will remain less than ideal. This is because they cannot directly influence the cause of the disease, but only attempt to influence one of the diseases physical manifestations. The therapy is directed on treating a secondary problem from a primary cause, and when the cause of the deformity is idiopathic it is hard to find the best solution to the problem. 8.1.4 Conclusion Based on the findings in section 7.1 and the information about adolescent idiopathic scoliosis, screening and treatment in part 1, the members of the project group are of the opinion that screening and treatment of adolescent idiopathic scoliosis need to be challenged in a number of areas to prove their reliability, validity and effect. Screening is a procedure to detect adolescent idiopathic scoliosis as early as possible, but it is seriously debated as a reliable method identifying this disease. The objective of screening is early detection of scoliotic curves. This may permit early initiation of conservative therapeutic measures that may prevent progression of the curves. However, the relationship between early detection and effect of conservative treatment of adolescent idiopathic scoliosis is questionable. Active exercises have not proven to prevent progression in degrees of the curve(s) in adolescent idiopathic scoliosis. Bracing remains the better choice of a non-operative treatment alternative due to its proven function in prevention of progression in degrees of the scoliotic curve. This conclusion is based, among other things, on the fact that research about screening and treatment has provided the scoliosis population with incomplete information, and that there are few protocols or guidelines to be followed. According to the information gained from this descriptive research, further knowledge about the natural history of adolescent idiopathic scoliosis is evidently required to improve the treatment and screening procedures used nowadays. The project group is of the opinion that more controlled clinical studies must be initiated, before any new approaches and instruments for screening and treatment are considered as an alternative. 9.1 Limitations of the project During the process of writing this research report the members of the project group were faced with both expected and unexpected problems that limited the project. This made it hard to work in the way and pace that the members of the project group had intended to. The difficulties started already when writing the project plan (FLP-format). This work was started while the members of the project group were still in Norway doing their clinical affiliation period. The members of the project group were in different parts of the country, and this meant that most of the preparation work had to be carried out through e-mails and mobile phones. Some of the members did not have access to Internet at home, and this made it even more difficult to co-operate and communicate in the preparation phase of the project. The FLP-format is an important part of the project, but it was hard to get a good start on the project when the first real group meeting to discuss the project together was not until 250302. The number of articles and relevant literature to be found turned out to be less than first imagined. Only a few of the articles found related to active exercises and adolescent idiopathic scoliosis. One article concerning active exercises was originally needed to be analysed, but it was not to be found either in Holland or Germany. After talking to Jan van de Braak, who is a physiotherapist at Sint Maartenskliniek, the project group was told that the amount of evidence-based and relevant literature concerning the subject was limited. It was also difficult to receive useful information from relevant persons and associations. Many different sources were contacted, but mostly the same information was referred to. This information consisted mainly of web sites that the project group already had found. There seems to be a generally limited knowledge on the subject adolescent idiopathic scoliosis in relation to active exercises and screening. The project group had counted on these persons and associations to have more information than they had. This made the process of finding information more time consuming than first anticipated. The language of the members of the project group is Norwegian. Writing in English makes it harder to find the right words and translations to be used in the project. The way of interpreting new terms to give them the right meaning makes the work harder and more time consuming. Some of the information that the project group found and decided to use was written in Dutch. This concerned especially information related to the visit at Sint Maartenskliniek. It was a difficult task translating this information, and it was more time consuming than making use of the Norwegian and English literature and articles. The amount of money the members of the project group could spend on the project was limited. Communicating with mobile phones is rather expensive. In addition travel and copy costs made the amount of money to be spent elsewhere limited. Thus, the group had to be more selective when buying background literature and other necessary information needed for the project. 9.2 What could have been done differently regarding the project? After finishing a project, it is always room for criticism of things that could have been done in another manner. Which activities were necessary, and which were not necessary. Before the clinical affiliation periods started, the various groups were put together and the members of the project group started thinking about the project. Proposals were handed in to the school, but it was until the beginning of December 2001 that the final decision about which group was to write which project was stated. If this process had started a bit earlier and the graduation topic had been sorted out before starting the clinical affiliation periods, the groups could have tried to gain more valuable information throughout these periods. This would have given the members of the project group more time preparing them for carrying out the project. When searching for information and relevant articles concerning adolescent idiopathic scoliosis and active exercises, it became apparent to the members of the project group that this search should have been started earlier. This is due to the fact that after searching for and finding articles about active exercises, it was decided to contact two scoliosis facilities. These facilities treat adolescents with idiopathic scoliosis, and the group saw it as relevant for the theoretical framework to gather information from these facilities. Due to the limited amount of time, the project group could only visit one of these facilities. The other facility did not give any feedback on the request for a visit. If this process had been started earlier it would possibly have given the project group the opportunity to visit both facilities. After analysing the articles using the data extraction form, the process of writing the results was the next step. Each group member analysed and wrote the results for a certain amount of articles. When putting together and editing the result section it became apparent that the results were not written in the same manner. It took some extra time to make the necessary changes in this chapter. It is paramount for the efficiency of conducting a research report to draw up clear guidelines concerning both content and lay out of the written material. In this way it can easier be assured that the material is written in a consistent manner. If the project group had clearly stated what this chapter should and should not contain earlier, this would have saved the amount of work for the members. With the development of the project it became apparent to the members that a more thorough investigation of the type and structure of the chosen research was needed. The members of the project group acknowledged the fact that it would have been necessary to study relevant literature to increase the knowledge in this field at an earlier point in time. This should have been done at the very start of the project. In this way the project would probably have been clearer to each project member, and a more equal understanding of the structure would have been achieved. 9.3 Recommendations for further research Based on the results, discussion and conclusion from this research it can be stated that more research concerning adolescent idiopathic scoliosis in relation to screening and treatment is needed. It is proposed that a randomised controlled clinical trial concerning screening and treatment of adolescent idiopathic scoliosis is conducted. There is a need for research results with a higher validity and reliability for adolescent idiopathic scoliosis in general. As stated in the discussion chapter, there exist certain limitations when it comes to carrying out such a research. The members of the project group are still of the opinion that a strive for valid and reliable information concerning this subject is acquired to be able to increase the quality of the treatment, and if possible, prevent progression of the curve(s) for adolescents with idiopathic scoliosis. 10.1 Literature References 10.1.1 Literature references for Part 1 1. Cailliet R. Scoliosis: diagnosis and management. The United States of America: F.A. Davis Company; 1975. 2. Machida M. Cause of idiopathic scoliosis. Spine 1999; 24 (24):2576-83. 3. Errico TJ. Adolescent idiopathic scoliosis. Adolescent idiopathic scoliosis (serial online( (cited 2002 April 10(: (14 screens(. Available from: URL:  HYPERLINK http://www.erricospine.com/Topics/Adolescent_Idiopathic_Scoliosi/body_adolescent_idiopathic_scoliosi.html http://www.erricospine.com/Topics/Adolescent_Idiopathic_Scoliosi/body_adolescent_idiopathic_scoliosi.html 4. Braak v.d. JWM. Kinderorthopedie. Idiopathische scoliose. In: Empelen v. R, Sanden v.d. R, Hartman A. Kinderfysiotherapie. Maarssen (NL): Elsevier gezondheidszorg; 2000. p. 273-85. 5. Lonstein JE. Natural history and school screening for scoliosis. Orthopedic Clinics of North America 1998 April 1;19:227-37. 6. Lawson D. The Scoliosis Centre. Introduction. (serial online( (cited 2002 April 10(: (3 screens(. Available from: URL:  HYPERLINK http://www.scoliosis.com.au/mainhome.htm http://www.scoliosis.com.au/mainhome.htm 7. Health tips: Scoliosis. Scoliosis. (serial online( (cited 2002 April 10(: (4 screens(. Available from: URL:  HYPERLINK http://www.covellichiro.com/english/pages/scol.html http://www.covellichiro.com/english/pages/scol.html 8. Winkel D, Aufdemkampe G, Matthiis O. Diagnosis and treatment of the spine: Nonoperative orthopaedic medicine and manual therapy. Maryland (the USA): Aspen Publishers, Inc; 1996. p.470-4. 9. Magee DJ. Orthopedic physical assessment. Philadelphia (the USA): W.B. Sauders Company; 1992. p. 243-5. 10. Idiopathic scoliosis. Understanding scoliosis, by spine health. (serial online( (cited 2002 April 10(: (8 screens(. Available from: URL:  HYPERLINK http://www.spine-health.com/topics/cd/scol/scol02.html http://www.spine-health.com/topics/cd/scol/scol02.html 11. Appley G, Solomon L. Concise System of Orthopaedics and Fractures. Cambridge (UK): University Press; 1994. p. 160-3. 12. Tidswell ME, editor. Cashs Textbook of Orthopaedics and Rheumatology for Physiotherapists. Aylesbury: BPCC Hazells Ltd; 1992. p. 192-213. 13. James JIP. Scoliosis. New York (the USA): Longman Inc.; 1976. 14. Dobbs MB, Weinstein SL. Infantile and juvenile scoliosis. The orthopedic clinics of North America 1999; 30 (3):331-9. 15. Dickson RA. Spinal Deformity Adolescent idiopathic scoliosis. Nonoperative treatment. Spine 1999; 24 (24):2601-6. 16. Idiopathic scoliosis infantile; juvenile; adolescent. In depth review of scoliosis: idiopathic scoliosis. (serial online( (cited 2002 April 10(: (2 screens(. Available from: URL:  HYPERLINK http://www.srs.org/htm/library/review/review05.htm http://www.srs.org/htm/library/review/review01.htm 17. LeBlanc R, Labelle H, Rivard CH, Poitras B. Relation between adolescent idiopathic scoliosis and morphologic somatotypes. Spine 1997; 22 (21):2532-6. 18. Lowe TG, Edgar M, Margulies JY, Miller NH, Raso VJ, Reinker KA, et al. Current concepts review: Etiology of idiopathic scoliosis: Current trends in Research. The Journal of Bone and Joint Surgery 2000; 82 (8):1157-69. 19. Kesling KL, Reinker KA. Scoliosis in twins. A metaanalysis of the literature and reports of six cases. Spine 1997; 22:2009-14. 20. Wheeless Textbook of Orthopaedics. Idiopathic scoliosis. (serial online( (cited 2002 April 10(: (3 screens(. Available from: URL:  HYPERLINK http://www.medmedia.com/o11/61.htm http://www.medmedia.com/o11/61.htm 21. Scoliosis. September 2001. (serial online( (cited 2002 April 10(:(27 screens(. Available from: URL:  HYPERLINK http://www.morehead.org/wellconnected/doc68.html http://www.morehead.org/wellconnected/doc68.html 22. Andersen MO, Thomsen K. Udredning og behandling af adolescent idiopatisk skoliose. Tidsskrift for Den norske lgeforening. (serial online( (cited 2002 April 10(:(8 screens(. Available from: URL:  HYPERLINK http://www.legeforeningen.no http://www.legeforeningen.no 23. British scoliosis research society. Etiology of adolescent idiopathic scoliosis. 10th International Philip Zorab Symposium. (serial online( (cited 2002 April 10(: (2 screens(. Available from: URL:  HYPERLINK http://www.ndos.ox.ac.uk/pzs/Index.html http://www.ndos.ox.ac.uk/pzs/Index.html 24. Ramirez N, Johnston CE, Browne RH. The prevalence of back pain in children who have idiopathic scoliosis. The Journal of Bone and Joint Surgery 1997; 79 (3):364-8. 25. Connecticut Childrens Medical Center. Idiopathic scoliosis. Orthopaedics. (serial online( (cited 2002 April 10(: (6 screens(. Available from: URL:  HYPERLINK http://www.ccmckids.org/departments/Orthopaedics/orthoed21.htm http://www.ccmckids.org/departments/Orthopaedics/orthoed21.htm 26. Gauchard GC, Lascombes P, Kuhnast M, Perrin PP. Influence of different types of progressive idiopathic scoliosis on static and dynamic postural control. Spine 2001; 26 (9):1052-8. 27. Cheng JCY, Guo X. Osteopenia in adolescent idiopathic scoliosis. A primary problem or secondary to the spinal deformity. Spine 1997; 22 (15):1716-21. 28. MEDLINEplus Medical Encyclopedia: Scoliosis. (serial online( (cited 2002 April 10(: (3 screens(. Available from: URL:  HYPERLINK http://www.nlm.nih.gov/medlineplus/ency/article/001241.htm http://www.nlm.nih.gov/medlineplus/ency/article/001241.htm 29. Lonstein JE. Adolescent idiopathic scoliosis. Lancet 1994; 334 (11):1407-15. 30. Karachalios T, Roidis N, Papagelopoulos PJ, Karachalios GG. Review of the Efficacy of school screening for scoliosis. Orthopeadics 2000 April 1; 23:386-90. 31. Morrissy RT. School screening for scoliosis. SPINE 1999 Dec 1; 24:2584-91. 32. International Pediatrics. The malignant Adolescent spine-part 1: AIS. [serial online] March 2002 [cited 2002 May]: [11 screens]. Available from :URL:  HYPERLINK http://www.int-pediatrics.org/newip/volumes/volume%2017/17-1/review/stricker/scoliosis.htm http://www.int-pediatrics.org/newip/volumes/volume%2017/17-1/review/stricker/scoliosis.htm 33. Warner JO, Metha MH. Scoliosis Prevention. Proceedings of the Philip Zorab Scoliosis Symposium 1983. New York (the USA): Praeger Publisher, 1985. p. 92-4, 126-40. 34. WebMD Health. Scoliosis. [serial online] Sep 1998 [cited 2002 April 12]: [21 screens]. Available from: URL: http://www.my.webmd.com/content/article/ 35. Killian JT, Mayberry S, Wilkinson L. Current concepts in adolescent idiopathic scoliosis. Pediatrics annals 1999; 28 (12):755-61. 36. Grossman TW, Mazur JM, Cummings RJ. An Evaluation of the Adams Forward Bend Test and the Scoliometer in a Scoliosis School Screening Setting. Journal of Pediatric Orthopeadics 1995; 15:535-8. 37. Cote` P, Kreitz BG, Cassidy JD, Dzus AK, Martel J. A Study of the Diagnostic Accuracy and Reliability of the Scoliometer and Adams forward bend test. SPINE 1998 April 1;23:796-803. 38. Tran NH. Scoliosis. Stanford Medical Center 1997 June ; 17 (1):11-21. 39. Weinstein SL. Virtual hospital: Adolescent idiopathic scoliosis. (serial online( (cited 2002 April 10(: (24 screens(. Available from: URL:  HYPERLINK http://www.vh.org/Providers/Textbooks/AIS/AIS.html http://www.vh.org/Providers/Textbooks/AIS/AIS.html 40. More exercise, Cotrel traction, Brace exercise, German gymnastics, Blount exercise. [serial online] [cited 2002 Feb 5]: [19 screens]. Available from: URL:  HYPERLINK "http://home.swipnet.se/~w-27587/Milwaukee/Text/Gympa1.html" http://home.swipnet.se/~w-27587/Milwaukee/Text/Gympa1.html,  HYPERLINK "http://home.swipnet.se/~w-27587/Milwaukee/Text/Gympa2.html" http://home.swipnet.se/~w-27587/Milwaukee/Text/Gympa2.html,  HYPERLINK "http://home.swipnet.se/~w-27587/Milwaukee/Text/Gympa3.html" http://home.swipnet.se/~w-27587/Milwaukee/Text/Gympa3.html,  HYPERLINK "http://home.swipnet.se/~w-27587/Milwaukee/Text/Cotrel.html" http://home.swipnet.se/~w-27587/Milwaukee/Text/Cotrel.html 41. Lehnert-Schroth C. Introduction to the three-dimensional scoliosis treatment according to Schroth. Physiotherapy, the journal of the chartered society of physiotherapy. 1992 Nov; 78 (11):810-15. 42. Weiss HR et al. Influence of an in-patient exercise program on scoliotic curve. Italian journal of orthopaedics and traumatology. 1992; 18 (3):395-9. 43. Robin GC. Scoliosis. 1st ed. New York (NY): Academic Press, Inc; 1973. 44. Athanasopoulos S, Paxinos T, Tsafantakis E, Zachariou K, Chatziconstantinou S et al. The effect of aerobic training in girls with idiopathic scoliosis. Scandinavian journal of medicine & science in sports. 1999 Feb; 9 (1):36-40. 45. Spineuniverse. Bracing for adolescent idiopathic scoliosis. [serial online] [cited 2002 April 5]: [3 screens]. Available from: URL:  HYPERLINK "http://www.spineuniverse.com/displayarticle.php/article1451.html" http://www.spineuniverse.com/displayarticle.php/article1451.html, Spineuniverse. Spinal bracing. [serial online] [cited 2002 April 8]: [1 screens]. Available from: URL:  HYPERLINK "http://www.spineuniverse.com/surgery/specialist/feature.html" http://www.spineuniverse.com/surgery/specialist/feature.html 46. BioConcepts. Orthotic treatment for idiopathic scoliosis. [serial online] [cited 2002 March 5]: [13 screens]. Available from: URL:  HYPERLINK "http://www.orthotic.com/scolio.html" http://www.orthotic.com/scolio.html 47. Moen KY, Nachemson AL et al. Treatment of scoliosis. A historical perspective. Spine. 1999; 24 (24):2570-606. 48. Lonstein JE, Winter RB et al. Adolescent idiopathic scoliosis, non-operative treatment. The orthopaedic clinics of North America 1988 April; 19 (2):239-46. 49. Kehl DK, Morrissy RT et al. Brace treatment in adolescent idiopathic scoliosis. An update on concepts and technique. Clinical orthopaedics and related research. 1988 April; 229:34-42. 50. Bradford DS, Tay BKB, Hu SS. Adult scoliosis: surgical indications, operative management, complications, and outcomes. Spine 1999; 24 (24):2617-29. 51. Rowe ED, Bernstein MS, Riddick FM, Adler F, Emans BJ, Gardner-Bonneau D et al. A meta- analysis of the efficacy of non-operative treatments of idiopathic scoliosis. The journal of bone and joint surgery. 1997 May; 79A (5):664-73. 52. Styblo K. Conservative treatment of juvenile and adolescent idiopathic scoliosis. Nijmegen (NL): [S.I.:s.n.]; 1991. 53. El-Sayyad M, Conine TA et al. Effect of exercise, bracing and electrical surface stimulation on idiopathic scoliosis: a preliminary study. International journal of rehabilitation research. 1994; 17 (1):70-4. 54. Mooney V, Gulick J, Pozos R et al. Apreliminary report on the effect of measured strength training in adolescent idiopathic scoliosis. Journal of spinal disorders. 2000; 13 (2):102-7. 55. Nancy N, Holland S, Jurek A, Serena S et al. Postural imbalance and vibratory sensitivity in patients with idiopathic scoliosis: Implications for treatment. The journal of orthopaedic & sports physical therapy. 1997 Aug; 26 (2):60-8. 56. Wong MS, Mak AFT, Luk KDK, Evans JH, Brown B et al. Effectiveness of audio-biofeedback in postural training for adolescent idiopathic scoliosis patients. The journal of the international society for prosthetics and orthotics. 2001 April; 25 (1):60-70. 57. Kooijman, Barends, Braak. Shift-therapie. Een behandeling voor kinderen met scoliose. Sint Maartenkliniek, Nijmegen (Brochure(. Nijmegen (NL): Trioprint, 1996. 58. Scoliosis. Australian Physiotherapy Association. Scoliosis. (serial online( (cited 2002 April 10(: (3 screens(. Available from: URL:  HYPERLINK "http://www.physiotherapy.asn.au/apacd/infocards/p10.htm" http://www.physiotherapy.asn.au/apacd/infocards/p10.htm Information from key figures: A. Braak J. Physiotherapist. Sint Maartenskliniek, Nijmegen, Holland. 160402. 10.1.2 Literature references for Part 2 59. Portney LG, Watkins MP. Foundations of Clinical Research-Applications To Practice. Connecticut (USA): Appleton & Lange; 1993. 60. Montgomery F, Willner S. Screening for idiopathic scoliosis. Acta Orthopaedica Scandinavica 1993 Aug; 64 (4):456-8. 61. Nachemson AL, Peterson LE et al. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. The journal of bone and joint surgery. 1995 June; 77A (6):815-20. 62. Goldberg CJ, Moore DP, Fogarty EE, Dowling FE et al. Adolescent idiopathic scoliosis. The effect of brace treatment on the incidence of surgery. Spine. 2001 Jan 1; 26 (1):42-7. 63. Allington NJ, Bowen JR et al. Adolescent idiopathic scoliosis: Treatment with the Wilmington brace. The journal of bone and joint surgery. 1996 July; 78A (7):1056-61. 64. Boer WA, Anderson PG, Limbeek J, Kooijman MAP. Treatment of idiopathic scoliosis with side-shift therapy: an initial comparison with a brace treatment historical cohort. European Spine Journal 1999; 8:406-10. 10.1.3 Recommended literature Cailliet R. Scoliosis: diagnosis and management. The United States of America: F.A. Davis Company; 1975. Braak v.d. JWM. Kinderorthopedie. Idiopathische scoliose. In: Empelen v. R, Sanden v.d. R, Hartman A. Kinderfysiotherapie. Maarssen (NL): Elsevier gezondheidszorg; 2000. p. 273-85. James JIP. Scoliosis. New York (the USA): Longman Inc.; 1976. Warner JO, Metha MH. Scoliosis Prevention.Proceedings of the Philip Zorab Scoliosis Symposium 1983. New York (the USA): Praeger Publisher, 1985. 11.1 Appendices Appendix 1: Definitive FLP format Appendix 2: Questions for visit to Sofies Minde and Sint Maartenkliniek Appendix 3: Data extraction form Appendix 4: Description of the literature search strategy and the used databases Appendix 5: Overview of the analysed articles presented in the result section Appendix 6: Figures for screening Appendix 7: Braces, casts and traction Appendix 8: Figures for treatment Appendix 9: Tables for result screening Appendix 1: Definitive FLP-Format Project Title of project: Active exercises and prevention of progression of an idiopathic scoliosis. Subtitle: A comparative analysis of the importance of detecting adolescent idiopathic scoliosis, and the effects of active exercises and bracing in treatment and prevention of progression of an adolescent idiopathic scoliosis. The group consists of: Andreas Paulsen Carsten Pedersen Morten Lund Christine Larsmon Date: 110402, version number 8. Project leader/ Commissioner Responsible for the project: Carsten Pedersen. Morten Lund. Andreas Paulsen. Christine Larsmon. Contact person: Carsten Pedersen. Supervisory teachers from the education: Graduation project co-ordinator: Annelies Simons. General supervisor: Eddy Salters. Methodological supervisor: Annelies Simons. Definition of the problem Previous history In 1991 Norsk Forening for Ryggforskning (NFR) was established, which is a scientific organisation for back problems. This organisation consists of a multidisciplinary team of physicians, physiotherapists and chiropractors. The purpose of this team is, among other things, to improve the knowledge concerning diagnosing and treatment within the health care groups that work with patients with back problems. Back problems, like for example scoliosis, spondylolisthesis, prolaps, acute lumbago and Morbus Bechterew, are one of the most common health problems today. Statistics from the industrialised world shows that between 60 to 80% of the population will get back problems to such a degree that sick leave is necessary for a shorter or longer period. In the USA back problems are estimated as the most frequent medical conditions limiting persons below 40 years of age in their leisure activities. In Sweden, back problems are responsible for 12 % of the sick leave. The same numbers are assumed to be found in Norway (1). Within the medical area back problem is still a topic that need more research. This is due to uncertainties concerning aetiology, diagnostics and treatment (1). The goal of NFR is to stimulate research activity and to spread information about back research to other health care disciplines, politicians and the public. Further on they want to increase multidisciplinary cooperation and understanding within the field of health care. In 1995 Statens Helsetilsyn published Vondt I ryggen Hva er det? Hva gjoer vi? (Pain in the back What is this? What do we do?), a work done by NFR in cooperation with Den norske legeforening, Norsk Fysioterapeuters Forbund and Norsk Kiropraktorforening. This publication contains clinical guidelines in treatment of the most common back problems, one of which is scoliosis. The goal of this work is to increase the level of quality of medical work on all levels of health care personnel working with patients with back problems. In addition this work can improve communication between the different health care disciplines for the benefit of both the patient and the professionals (1). Back pain can roughly be divided into two categories according to its origin: In movable segments or soft tissue. Pain with or without nervous tissue symptoms. According to NFR, scoliosis is regarded as a back problem with origin in the movable segments without any nerve root pain (1). Idiopathic scoliosis is an acquired deformity of the spinal column that appears in childhood, and represents today as the most common and important type of scoliosis. In the general population NFR estimates a frequency of approximately 1,5 2,0 % of idiopathic scoliosis. These numbers are variable, depending on how the deformity of idiopathic scoliosis is defined and the concerned age group (1). The differences in percentages can be explained in the fact that some examiners record even the slightest asymmetry as an idiopathic scoliosis, while others include only the curves of 10 degrees or more (2). An epidemiological research conducted in the northern part of Norway on children from 7 18 years of age, shows a frequency of 1,3 % of idiopathic scoliosis (1). Idiopathic scoliosis occurs usually in children from 9 15 years of age (adolescent idiopathic scoliosis), but it can also occur earlier. These cases are referred to as infantile (0 3 years of age) or juvenile (4 8 years of age) idiopathic scoliosis (1). The definitions of the three groups of idiopathic scoliosis differ concerning the age groups in the literature (1,2,3). There are variations of approximately ( one year in each direction in all the groups. Infantile and juvenile idiopathic scoliosis are more rare conditions compared to adolescent idiopathic scoliosis (1). Adolescent idiopathic scoliosis is the most common form of idiopathic scoliosis (3). Based on these facts, it was decided to focus on adolescent idiopathic scoliosis in this project. Adolescent idiopathic scoliosis is described as starting between 9 and 10 years up to 15, 16 years or when the growth spurt stops (1,2,3). To avoid excluding important information concerning the topic of idiopathic scoliosis, the following age group will be used in this project; from 9 years until the growth spurt stops. Depending on the literature, 80 90 % of patients with adolescent idiopathic scoliosis are girls (1,3, A). Adolescent idiopathic scoliosis is a challenging and complicated problem. Biological and mechanical factors can together cause a disease process that can develop to a cosmetic deformity, and in the end pain in the muscular-skeletal system due to mechanical irregularities (4). In addition diminished lung function can, with severe curves, lead to heart problems and in the end to death (2). There exist several different treatment alternatives for adolescent idiopathic scoliosis, like bracing, surgery and exercises. The choice of treatment for adolescent idiopathic scoliosis has changed through the years. Degrees of the curve, pain and quality of life are important aspects when considering treatment of adolescent idiopathic scoliosis (5). Vondt I ryggen Hva er det? Hva gjoer vi? states that the treatment methods in Norway in connection with scoliosis are limited to bracing and operations (1). This statement was confirmed by an orthopaedic engineer at Sofies Minde, a competence centre in Norway for scoliosis, and he advised the project group to search for information in Holland concerning alternative treatments for patients with adolescent idiopathic scoliosis (A). The project group found the information in Norway about the effect of active exercises and adolescent idiopathic scoliosis to be insufficient. In addition, the knowledge about active exercises and bracing, both separate and in combination, as a preventive treatment for adolescent idiopathic scoliosis within the project group is limited. Within physiotherapy, information and awareness are important aspects in relation to treatment of different back problems, in addition to active exercises (1). Concerning adolescent idiopathic scoliosis the role of the physiotherapist is mostly limited to pre- and post- operative treatment in addition to applying the brace (5). The knowledge about physiotherapy in relation to treatment of adolescent idiopathic scoliosis within the project group is limited. Based on this the project will focus on the physiotherapists role in relation to active exercises in treatment and prevention of adolescent idiopathic scoliosis. Detecting an adolescent idiopathic scoliosis is difficult because this condition usually gives no subjective symptoms. This is why screening of children is important. Often a child is too old when it is detected that he or she is suffering from an adolescent idiopathic scoliosis. The earlier an adolescent idiopathic scoliosis is detected, the more chance it is that treatment in some form will help (1, A). Those children not being diagnosed at the beginning of the development of their adolescent idiopathic scoliosis will probably have a lower chance of being prevented from progressing further with that scoliosis. In Norway there is no standard screening of school children for adolescent idiopathic scoliosis. (1, A). Based on this the project group decided to search for information about the importance of screening to permit early diagnosing. Social and/or scientific relevancy: Increase the knowledge for future physiotherapy students and future colleagues about the different alternatives of treatment and prevention of progression of idiopathic scoliosis. Increase the quality of physiotherapeutic treatment for patients with adolescent idiopathic scoliosis. The members of the project group have interest in working with patients with adolescent idiopathic scoliosis in the future, and see this as an opportunity to broaden their horizons in this field. Research questions: Background question/ theoretical framework: - Which forms of idiopathic scoliosis exist in relation to aetiology, signs, symptoms, prognosis and treatment? Main question 1: - What are the interventions for detecting adolescent idiopathic scoliosis as early as possible? Sub questions: Does there exist a screening-procedure in general on how to detect adolescent idiopathic scoliosis? What is the content of such a screening-procedure, and who is performing this procedure? What are the advantages of detecting adolescent idiopathic scoliosis as early as possible? What are the disadvantages of detecting adolescent idiopathic scoliosis late? What is the relationship between time of detection through screening and treatment result of adolescent idiopathic scoliosis? Main question 2: - What is the effect of active exercises and bracing on a patient with adolescent idiopathic scoliosis in relation to preventing progression in degrees of the curve(s) of that scoliosis? Sub questions: a) What are the existing treatment alternatives in relation to active exercises and bracing, separate and in combination, for a person with adolescent idiopathic scoliosis? b) What are the advantages/disadvantages of the use of bracing and active exercises, separate and in combination, for the treatment of adolescent idiopathic scoliosis? c) What is the physiotherapists role/task in the treatment of adolescent idiopathic scoliosis? Working definitions: - Active exercises: Exercises performed by the patient him/herself, guided only verbally by the physiotherapist. These exercises are aiming at correcting the imbalance in the muscular-skeletal system through rehabilitation, and increasing the muscular strength, muscular-stamina, and stretch ability (1. p. 38). Adolescent idiopathic scoliosis: a person with idiopathic scoliosis from 9 years until growth spurt stops (1. p. 48,3. p. 472). - Brace = orthosis. An individually made surgical appliance that provides support for an unstable joint or joints (6, p. 469). Idiopathic scoliosis: A structural (fixed lateral curvature with a rotatory component) lateral curvature of the spine presenting at or about the onset of puberty and before maturity for which no cause is established (7. p. 1). Prevention: To limit the development of an idiopathic scoliosis in relation to size of curvatures and progression (1). Progression: An increase in the magnitude of the scoliosis (1). - Scoliosis: lateral (sideways) deviation of the backbone, caused by congenital or acquired abnormalities of the vertebrae, muscles and nerves. (6. p. 592). - Screening: A simple test carried out on a large number of apparently healthy people to separate those who probably have a specified disease from those who do not. (6. p. 592). 3. Objectives Description of background information about idiopathic scoliosis concerning aetiology, signs, symptoms, prognosis and treatment. An overview into the importance of detecting adolescent idiopathic scoliosis as early as possible. Description of different methods of treating and preventing further progression in degrees of the curve in adolescent idiopathic scoliosis. An introduction into the role/task of the physiotherapist in the treatment of a patient with an adolescent idiopathic scoliosis. 4. Method Literature study on different sources: Databases: Medline, Cochrane, Cinahl, Pedro, and Doconline. Special databases: Vubis, Picarta. Information from key figures: Sofies Minde; hospital, competence centre for scoliosis. Orthopaedic engineer Svein Ivar Olsen. Competence centre in Holland; Jan v.d Braak; St. Maartenskliniek in Nijmegen. Scoliosis Association, New York. Norwegian scoliosis association. d) Other sources of information: here the quality of the found literature will have to be tested on validity and reliability. Search engines:  HYPERLINK "http://www.bibsys.no" www.bibsys.no  HYPERLINK "http://www.pubmed.com" www.pubmed.com  HYPERLINK http://www.yahoo.com www.yahoo.com  HYPERLINK http://www.altavista.com www.altavista.com Web sites:  HYPERLINK "http://www.fysioterapeuten.no" www.fysioterapeuten.no  HYPERLINK "http://www.medscape.com" www.medscape.com  HYPERLINK "http://www.vh.org" http://www.vh.org  HYPERLINK "http://www.spinejournal.com" http://www.spinejournal.com  HYPERLINK "http://www.helsetilsynet.no" www.helsetilsynet.no  HYPERLINK "http://www.apta.org" www.apta.org Literature from the library at Fontys Hogeschool/ TF Eindhoven: Winkel D, Aufdemkampe G, Matthiis O. Diagnosis and treatment of the spine: Nonoperative orthopaedic medicine and manual therapy. Maryland (USA): Aspen Publishers, inc.; 1996. p. 470-474. Magee DJ. Orthopedic physical assessment. The United States of America: W.B. Saunders Company; 1992. p. 243-245. Appley G, Solomon L. Concise System of Orthopaedics and Fractures. Cambridge (UK): University Press; 1994. Testing the web sites mentioned above for validity and reliability. Search strategies: Search words: this includes keywords, free text words and MESH headings; these will be used with Booleans such as AND/NOT/OR, both alone and in combination. The validity and reliability of the web sites will be tested before they are used. Addresses from Internet containing relevant literature will be documented with the date for the search. It will be described how the databases are found. Search wordsMain question 1CombinationsMain question 2CombinationsEnglish1.Adolescent/Youth 2.Detection 3.Idiopathic 4.Intervention 5.Scoliosis 6.Screening 7.Treatment 1.AND 3. 1.AND 5. 2.AND 5. 3.AND 5. 5.AND 6. 5.AND 7. 5.AND 4. 1.Adolescent/Youth 2.Bracing/Orthosis 3.Degree 4.Exercise/Training 5.Idiopathic 6.Physiotherapist 7.Prevention 8.Progression 9.Scoliosis 10.Treatment1.AND 9. 3. AND 9. 4. AND 9. 6. AND 9. 8. AND 9. 10. AND 9. 5. AND 9. 7. AND 9. 2. AND 6. 6. AND 4.Norwegian1.Behandle 2.Idiopatisk 3.Fremgangsmte 4.Oppdage 5.Ungdom 6.Utvelging 7.Scoliose6.AND 7. AND 3. 3. AND 7. 1. AND 7. 1.Behandle 2.Forhindre 3.Fysioterapeut 4.Grader 5.Idiopatisk 6.Korsett 7.Oekning 8.Oevelser 9.Ungdom 10.Scoliose 10. AND 8. 4. AND 10. 5. AND 10. 3. AND 6. 5. AND 9. AND 10. 3. AND 8.  Inclusion and exclusion criterias. - The article has to be relevant regarding idiopathic scoliosis. The article has to be written in Norwegian, English or Dutch. Main focus on information from Norway and Holland, but relevant literature from other countries will be included The article/research has to be found in full format. The article/research must cover one or more of the key words described above. Patient: a person (sex is unimportant), with idiopathic scoliosis from 9 years of age until the growth spurt stops. Idiopathic scoliosis without the influence of other disorders and diseases. The year 1966, when Medline started, and more recent material is set as time limit for the use of articles/information. All relevant research material concerning idiopathic scoliosis from health care institutions can be included. Articles containing active exercises and/or bracing can be included. Articles containing screening of adolescent idiopathic scoliosis can be included. Articles containing quality of life in relation to adolescent idiopathic scoliosis can be included. The name of the author is not relevant. Articles with surgery in the main-title will be excluded. Use the criterias to decide what of the found literature will be used and what will not be used. Interviewing expert person at Sofies Minde, a scoliosis competence centre in Norway; Svein Ivar Olsen. Interviewing an expert person; Jan v.d. Braak, Sint Maartenskliniek, Nijmegen, Holland. Data extraction list for all the articles; this will include criterias as validity and reliability for the articles. This list will be used in order to extract the information of all the material found. Data analysis and data synthesis: this will include what is the exact result of the data extraction. 5. Project products - End product report. - Individual evaluation reports. - Title of the project and a short summary. - Handout for the presentation. - Verbal presentation. 6. Time 6.1 Time schedule and 6.2 Phasing of project activities WEEKDATEACTIVITYNAMES2305-06-01Introduction into graduation projectAll + Annelies2309-06-01Deliver list of private numbers, addresses and e-mail addresses to Paul and AnneliesAll2415-06-01Deadline group informationAll4111-10-01 before 16.00 p.m.Hand in project proposalCarsten44From 30-10-01Gather information about idiopathic scoliosisAll4508-11-01Official approval of proposalsGraduation committee4723-11-01Proposals sent by e-mail to studentsAnnelies4830-11-01Express preference for proposalAll4906-12-01Division of project to groups, announcement to groups and coupling of two supervisors to the project.Annelies5010-12-01INITIATION/DEFINITION PHASE2-310-01-02Deliver first FLP format to general supervisorAll3-420-01-02Making changes on FLP formatCarsten, Andreas, Christine528-01-02Deliver FLP format version 2 to AnneliesAll529-01-02Make changes on FLP formatCarsten, Andreas, Christine531-01-02Deadline Pre-definitive FLP formatAll501-02-02PREPARATION PHASE605-02-02Making changes on FLP formatAll608-02-02Review of the Pre-definitive FLP formatGraduation committee818-02-0222-02-02Contact methodological supervisorAll9-1125-02-0215-03-02Revisions FLP formatAll1010-03-02Formulate questions for visit to Sofies Minde, based on objectives of the project.Carsten, Andreas1112-03-02Interview at Sofies MindeCarsten, Andreas1325-03-02REALISATION PHASE1325-03-02All students back in HollandAll1327-03-02Group meeting; rules.All1327-03-02Deliver FLP format version 3Andreas, Morten, Christine1328-03-02Make changes on FLP formatAll1328-03-02Group meeting. Update progression and problems.All1328-03-02Discussing the role of each group member; strengths and weaknesses.All1328-03-02Introduction to searching strategiesAll1328-03-02Deliver FLP format version 3b.All1331-03-02Group meeting. Update progression and problems.All1331-03-02Making data extraction listMorten, ChristineWEEKDATEACTIVITYNAMES1301-04-02Group meeting. Update progression and problems.All1401-04-02Deliver FLP format version 4All1401-04-02Divisions of tasksAll1402-04-02Meeting with methodological supervisorAll1402-04-02Group meeting. Update progression and problems.All1403-04-02Make changes on FLP formatAll1403-04-02Deliver FLP format version 5All1403-04-02Contact Scoliosis Association, New York. Ask for relevant information.Morten1404-04-02Meeting with general supervisorAll1404-04-02Group meeting. Update progression and problems.All1404-04-02Make changes on FLP formatAll1404-04-02Deliver FLP format version 6All1404-04-02Contact University of Oslo. Ask for relevant information.Christine1405-04-02Contact Jan v.d Braek; St. Maartenskliniek in Nijmegen, Holland. Make appointment for visit.Morten1405-04-02Group meeting. Update progression and problems.All1405-04-02Search in MedlineCarsten1405-04-02Search in PedroAndreas1405-04-02Search in CinahlMorten1405-04-02Search in CochraneChristine1406-04-02Make changes on FLP formatAll1407-04-02Deliver FLP format version 7All1508-04-02 13.45-14.30Meeting with general supervisorAll1508-04-02Gather information about treatment alternatives in Norway by contacting (e-mail/telephone) relevant associations, centres and persons.Christine, Morten1508-04-02Gather information about treatment alternatives in Holland by contacting (e-mail/telephone) relevant associations, centres and persons.Carsten1508-04-02Gather information about treatment alternatives in the USA by contacting (e-mail/telephone) relevant associations, centres and persons.Morten1508-04-02Group meeting. Update progression and problems.All1509-04-02Prepare search at Amsterdam Medical LibraryAll 1509-04-02Prepare questions for visit toScoliosis competence centre in NijmegenAndreas, Carsten 1510-04-02Visit Amsterdam Medical Library to find articles searched for on Internet about the subject. (NIWI)All1511-04-02Deliver definitive FLP format. Version 8.All1511-04-02Visit scoliosis competence centre in Nijmegen, Holland; interviewing an expert person.Carsten, Andreas1512-04-02Group meeting. Update progression and problems.All1615-04-02 12.00-13.00Meeting with general supervisorAll1615-04-02Apply inclusion and exclusion criterias on the found literature.Andreas, Morten1615-04-02Assess relevant literature in relation to main questions, sub questions and methodological quality.Christine, Carsten 1615-04-02Apply data extraction listAll1615-04-02Data analysis and data synthesisAll1615-04-02Group meeting. Update progression and problems.All1616-04-02Write about different forms of adolescent idiopathic scoliosisChristine 1616-04-02Write about the physiotherapists role/task in treatment of adolescent idiopathic scoliosisAndreasWEEKDATEACTIVITYNAMES1616-04-02Write about screening procedures for adolescent idiopathic scoliosisCarsten1618-04-02Group meeting. Update progression and problems.All1618-04-02Writing about active exercises for adolescent idiopathic scoliosisChristine1618-04-02Write about bracing and the effect of bracing in combination with active exercisesMorten1722-04-02 12.00-13.00Meeting with general supervisorAll1722-04-02Group meeting. Update progression and problems.All1725-04-02 12.00-13.00Meeting with general supervisorAll1725-04-02Group meeting. Update progression and problems.All18-1929-04-02 10-05-02HolidayTeachers1829-04-02Group meeting. Update progression and problems.All1830-04-02Write IntroductionCarsten, Morten1830-04-02Write ResultsChristine, Andreas1801-05-02Make content listMorten1801-05-02Make front page of reportAndreas1801-05-02Introduction to power point presentationAll1802-05-02Group meeting. Update progression and problems.All1802-05-02Write AbstractMorten, Christine1802-05-02Write ForewordAndreas, Carsten1803-05-02 04-05-02Write methodCarsten, Christine1803-05-02 04-05-02Write discussion and conclusionAndreas, Morten1906-05-02Write appendicesAndreas 1906-05-02English spell checkCarsten1906-05-02Group meeting. Update progression and problems.All 1907-05-02Coordinate abstract, foreword, method, discussion, and conclusion. Draft 1.All1907-05-02Group meeting. Update progression and problems.All1909-05-02Group meeting. Update progression and problems.All1910-05-02Group meeting. Update progression and problems.All2013-05-02 12.00-13.00Meeting with general supervisorAll2013-05-02Group meeting. Update progression and problems.All2013-05-02Coordinate abstract, foreword, method, discussion, and conclusion. Draft 2.All2014-05-02Group meeting. Update progression and problems.All2015-05-02Complete literature listCarsten, Christine2016-05-02Group meeting. Update progression and problems.All2120-05-02Make title and short descriptionMorten, Andreas2120-05-02Group meeting. Update progression and problems.All2121-05-02Make a power point presentation with hand outsAll 2121-05-02Evaluation of power point presentation.All2121-05-02Evaluation and correction of handoutAll2122-05-02 12.00-13.00Meeting with general supervisorAllWEEKDATEACTIVITYNAMES2123-05-02Group meeting. Update progression and problems.All2123-05-02Editing end productAll2123-05-02Group deadline end productAll2123-05-02Deliver end product to general supervisorAll2123-05-02Write individual reportsAll2123-05-02REPORTING PHASE2123-05-02 before 12.00 a.m.Deliver title and short descriptionAll2124-05-02Group meeting. Update progression and problems.All2227-05-02Copying and binding of project reportAll2227-05-02 13.00-14.00Meeting with general supervisor. Evaluation of end product report.2227-05-02Work on feedback from general supervisor on end product report.All2227-05-02Group meeting. Update progression and problems.All2227-05-02Rehearsal presentationAll2230-05-02 before 12.00 a.m.Deliver end products All2230-05-02Group meeting. Update progression and problems.All2231-05-02Rehearsal presentationAll2303-06-02Group meeting. Update progression and problems.All2305-06-02Group meeting. Update progression and problems.All2305-06-02Presentation rehearsalAll2305-06-02 before 12.00 a.m.Deliver individual reportAll2306-06-02Group meeting. Update progression and problems.All2307-06-02 09.00-10.00Rehearsal presentationAll + GS2307-06-02 09.00-10.00Evaluation rehearsal presentationAll + GS2307-06-02 10.00-10.30Individual discussion with general supervisorCarsten2307-06-02 10.30-11.00Individual discussion with general supervisorChristine2307-06-02 11.00-11.30Individual discussion with general supervisorMorten2307-06-02 11.30-12.00Individual discussion with general supervisorAndreas2309-06-02Group meeting. Update progression and problems.All2410-06-02Rehearsal presentationAll 2412-06-02Group meeting. Update progression and problems.All2412-06-02Assessment of end productGeneral and methodological supervisor2413-06-02Presentation graduation projectAll2414-06-02Exam meetingTeachers2414-06-02Graduation delivering gradesAll Supervision: Regularly communication with Eddy Salters and Annelies Simons by telephone, e-mail and meetings. This is stated in the time schedule in 6.1 Estimated costs Activities/materialsCostsCopy/printing/binding costs 100, -Telephone costs 20, -Travelling costs 50, -Information from the Internet 30, -Unexpected costs 40, -Total: Approximately: 250, - Quality requirements Functional demands: Informative report based on reliable and valid information. The reader should easily find the information he or she wants. No unnecessary information and having a clear language. Operational demands: Written in Great Britain English. Written with a terminology meant for people with already some knowledge of medical terms. Boundary conditions: Schillings M, Simons A. Principles and requirements of the Graduation Project manual. (Study Guide ES4 Period 12-16(. Eindhoven: Fontys University of Higher Professional Education; March 2001. Title page = first page: The title Name of author(s) and supervisor(s). Research report Fontys University of Higher Professional Education Department of Physiotherapy Date Content of the report: Title Foreword Abstract/Summary Contents Introduction Chapters: introduction, method, results, discussion and conclusion. Literature references Appendices Printed on A4 papers. Numbered pages, printed on both sides. Explanations with optimal information will be placed next to tables and diagrams. Diagrams and tables is numbered with Arabic numbers, and referred to in the text with numbers. Bind the project report. Volume of the report; 40-60 pages (excluding appendices). Times New Roman, fond size 11. Design limitations: The distance between the group members while working on the preparation phase while still in Norway made communication difficult. Misunderstandings regarding the English language. The language knowledge in the project group is limited to Norwegian and English. Limited skills in Dutch; could not make use of some of the valuable information from Holland. Unexpected costs. Difficulties finding information/ getting access to wanted information in articles. Problems getting in contact with the necessary people. Limited access to Internet (reserving computers). Limited skills in searching strategies on Internet. Accidental deletion of files/computer crash Provisional literature 1. Statens Helsetilsyn (N). Vondt I ryggen Hva er det? Hva gjoer vi? Oslo; 1995. 2.Winkel D, Aufdemkampe G, Matthiis O. Diagnosis and treatment of the spine: Nonoperative orthopaedic medicine and manual therapy. Maryland (USA): Aspen Publishers, inc.; 1996. p. 470-474. 3. Appley G, Solomon L. Concise System of Orthopaedics and Fractures. Cambridge (UK): University Press; 1994. 4. White A, Panjabi M. Clinical Biomechanics of the Spine. Pennsylvania: J.B Lippincott company; 1990. 5.Tidswell ME. Cashs Textbook of Orthopaedics and Rheumatology for Physiotherapists. Aylesbury: BPCC Hazells Ltd; 1992. p. 192-213. 6. Concise Medical Dictionary. 4th ed. Cambridge (UK): University Press; 1994. Orthosis; p 469. 7. Weinstein SL. Virtual Hospital: Adolescent Idiopathic Scoliosis. (serial online((cited 140302) (screens(http://www.vh.org/providers/Textbooks/AIS/01AIS.html - Information from key figures: A. Olsen IS, Sofies Minde, Scoliosis competence centre, Norway. 15-03-02. APPENDIX 1: GRADUATION PROJECT PROPOSAL PROPOSAL 2: Graduation project proposal 2001 2002 ES4 1. Title: Active exercises and prevention of idiopathic scoliosis. 2. Responsibility for proposal Andreas Paulsen Carsten Pedersen. 3. Problem description In Norway patients with idiopathic scoliosis are not given any exercises to prevent progression of an idiopathic scoliosis. We wish to emphasise on active exercises and scoliosis, and look for differences in the treatment of an idiopathic scoliosis. More information should be added to this by the commissioners! What exactly is the problem? Main question: Can active exercises help prevent progression of an idiopathic scoliosis? Sub questions: Needs to be formulated by commissioners 4. Objectives Needs to be formulated by commissioners. What is exactly your objective with this project? 5. Proposed activities Literature study on idiopathic scoliosis and therapy possibilities Visit orthopaedic engineering workshop to gather/gain info about scoliosis/braces/treatment. Compare treatments in Holland and Norway Judge data by means of a check list Analysing data in order to answer main question and sub questions 6. Products End product report Educational product: brochure / Exercise program 7. Globally estimated costs Approximately Fl. 600, -- 8. Number of participating students: 4 Morten Lund Carsten Pedersen Andreas Paulsen Christine Larsmon APPENDIX 2 APPROVAL OF FINAL FLP FORMAT Date: Place: General supervisor: Eddy Salters Methodological supervisor: Annelies Simons Students: Morten Lund Andreas Paulsen Carsten Pedersen Christine Larsmon Appendix 2: Questions for visit to Sofies Minde and Sint Maartenskliniek. Questions concerning adolescent idiopathic scoliosis (AIS) and active exercises, braces, screening, treatment results, alternative treatments, and quality of life. - Screening Is screening for AIS a standard procedure in Norway/Holland? At what age is the screening performed? Who performs the screening of AIS? And what does the screening contain? What is the effect of an early screening-procedure? Are the costs of having a standard screening program for AIS too expensive? What happens when a person with AIS is detected? At what age is the AIS usually detected? Do you know any statistics of the prevalence of AIS in Norway/Holland? Do you have any theories about how idiopathic scoliosis develops? - Treatment What age groups with AIS are most common at your clinic? What kind of treatment procedures do you have for people with AIS? Can the physiotherapist take a bigger role in treatment of AIS? What role should the physiotherapist have when treating AIS? - Active Exercises Are you using any active exercises in the treatment of a patient with AIS? Is there any standard protocol for conservative treatment of AIS? What kind of literature do you recommend for us to learn more about active exercises as a treatment approach to AIS? - Bracing What are the negative/positive effects of bracing in AIS? Are you combining brace and active exercises, or only active exercises in the treatment of AIS? What is your opinion of the best treatment of AIS so far? Why? - Quality of life Can you tell something about quality of life for a patient with AIS? Appendix 3: Data extraction list and assessment of methodological quality. The evaluation of a systemic review of controlled clinical trials or reviews of diagnostic and/or therapeutic literature. Material controlled by: Date of control: Title: Author(s): Source: Publisher: Type of study: Country: Year of publishment: The Pedro scale is used to assess the methodological quality of the article: 1. Eligibility criteria were specifiedNo: Yes:2. Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received).No: Yes:3. Allocation was concealed.No: Yes:4. The groups were similar at base line regarding the most important prognostic indicators.No: Yes:5. There was blinding of all subjects.No: Yes:6. There was blinding of all therapists who administered the therapy.No: Yes:7. There was blinding of all assessors who measured at least one key outcome.No: Yes:8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups.No: Yes:9. All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by intention to treat.No: Yes:10. The results of between-group statistical comparisons are reported for at least one key outcome.No: Yes:11.The study provides both point measures and measures of variability for at least one key outcome.No: Yes: Two data extraction forms (A and B) are combined. A is for articles concerning diagnosis and screening. B is for articles concerning treatment and prevention. The section Method and Participants will be used in the data extraction for both A and B. METHOD: - Study duration: - Type of trial: - Amounts of dropouts and crossovers: - Co interventions: - Validity criteria:  - Reliability: - Statistical measurements: - Bias:  PARTICIPANTS: - Age: -Sex: - Settings of studies:  - Diagnostic criteria: Infantile Juvenile Adolescent Aetiology Signs and symptoms Prognosis Treatment Screening - Appropriate patient sample: - Control group:  A. ARTICLES RELATED TO DIAGNOSIS/SCREENING: METHOD: - Description of screening procedure: - Time of screening: - Who carries out the screening:  - Intrarater reliability: - Interrater reliability:  - Advantages of screening: - Disadvantages of screening:  - Description of relationship between time of detection and result of treatment of adolescent idiopathic scoliosis:  RESULTS: - Are the results in the study valid: Appropriate spectrum of patients. Sufficient description of the method for performing the test.  - What are the results: Are ratios for the test results presented/ data necessary for calculation of results provided. Significant results  - Are the results applicable for a patient with adolescent idiopathic scoliosis:  B. ARTICLES RELATED TO TREATMENT/ PREVENTION INTERVENTION: - Type of intervention: Active exercises Bracing Active exercises and bracing in combination  - Treatment length:  - Measurement time:  - Follow up length:  - Intervention for control group:  - Who delivered the intervention: physiotherapist orthopaedic engineer  - Content of intervention: Advantages Disadvantages  OUTCOME MEASURES: - Measurement tools: Cobbs angle Pain Quality of life Mobility Strength Coordination Motor skills  RESULTS: - Results of treatment: Effects of active exercises alone Effects of bracing alone Effects of bracing and active exercises in combination Preventing progression in degrees of the curve(s) Physiotherapists role/task Significant results/effect  - Are the results applicable to a patient with adolescent idiopathic scoliosis:  OTHER REMARKS:  Appendix 4: Description of the literature search and the used databases Some literature was collected in Norway while the members of the project group still had their clinical affiliation period there. This literature mostly consisted of information found on the Internet, and it was to be used in the theoretical framework. All the members of the project group had individually searched for information concerning the subject in the period from January 2002 to March 2002. During this period two of the members of the project group made questions and visited Sofies Minde for conducting an interview with an orthopaedic engineer. The information collected besides the articles to analyse, was used to build up the theoretical framework needed to describe the subject. Description of search in the different databases: All the members of the project group, searched after articles in the period 01-04-02 to12-04-02. The databases were divided between the members, and a systematic search using the key words, free text words, MESH headings, combinations, and synonyms were conducted. For detailed information about all key words in English and Norwegian see appendix 1, FLP-format. When each member had finished his or her search in a certain database, a second member of the project group made a new search in the same database. This was done to increase the validity and reliability of the search, and to find the most suitable for articles for the project. All that was found on the databases consisted of abstracts from articles published in different magazines. To be included in this project, the article had to be found in full format (see inclusion and exclusion criterias appendix 1, FLP-format), and the original articles had to be collected. Two of the members of the project group went to NIWI in Amsterdam on 15-04-02 to copy and collect the complete articles. Overview over the web sites searched in: All the members of the project group continued to search for information on the Internet, and the majority of the searches were conducted from 01-04-02 to 12-04-02. Relevant information was searched for in the following web sites:  HYPERLINK http://www.fysioterapeuten.no www.fysioterapeuten.no,  HYPERLINK http://www.medscape.com www.medscape.com,  HYPERLINK http://www.vh.org http://www.vh.org,  HYPERLINK http://spinejournal.com http://spinejournal.com,  HYPERLINK http://www.helsetilsynet.no www.helsetilsynet.no,  HYPERLINK http://www.apta.org www.apta.org,  HYPERLINK http://www.spineuniverse.com www.spineuniverse.com,  HYPERLINK http://www.scoliosis.org www.scoliosis.org,  HYPERLINK "http://www.scoliosis_assoc.org" www.scoliosis_assoc.org,  HYPERLINK http://www.iscoliosis.com www.iscoliosis.com,  HYPERLINK http://www.orthospine.com www.orthospine.com,  HYPERLINK http://www.nih.gov/niams/healthinfo www.nih.gov/niams/healthinfo,  HYPERLINK http://www.spine_surgery.com www.spine_surgery.com,  HYPERLINK http://www.kidshealth.org www.kidshealth.org,  HYPERLINK http://www.spine_health www.spine_health,  HYPERLINK http://www.allaboutbackpain.com www.allaboutbackpain.com,  HYPERLINK http://www.scoliosiscorrection.com www.scoliosiscorrection.com,  HYPERLINK http://www.scoliosishelp.org www.scoliosishelp.org,  HYPERLINK http://www.scoliosisrx.com www.scoliosisrx.com,  HYPERLINK http://www.who.org www.who.org,  HYPERLINK http://www.bmj.org www.bmj.org,  HYPERLINK http://www.coolware.com/health/medical_reporter/scoliosis.html http://www.coolware.com/health/medical_reporter/scoliosis.html,  HYPERLINK http://www.concentric.net/~pjr-spoc http://www.concentric.net/~pjr-spoc, http://www.scoliosisassociates.com/,  HYPERLINK http://www.peds-ortho.com http://www.peds-ortho.com, text.nlm.nih.gov/cps/www/cps.53.html - 56k, www.rad.washington.edu/mskbook/scoliosis.html - 17k, http://pubs.ama-assn.org/,  HYPERLINK http://www.keepkidshealthy.com/welcome/conditions/scoliosis.html http://www.keepkidshealthy.com/welcome/conditions/scoliosis.html, www.allkids.org/Epstein/Articles/Scoliosis.html - 7k, www.noah-health.org/english/illness/orthop/scoliosis.html - 20k, www.chirobase.org/07Strategy/scoliosis.html - 6k,  HYPERLINK http://www.ccmckids.org/departments/Orthopaedics/orthoed21.htm http://www.ccmckids.org/departments/Orthopaedics/orthoed21.htm,  HYPERLINK http://webmd.lycos.com/content/article/1680.51919 http://webmd.lycos.com/content/article/1680.51919,  HYPERLINK http://www.edweek.org/ew/ew_printstory.cfm?slug=12health.h19 http://www.edweek.org/ew/ew_printstory.cfm?slug=12health.h19,  HYPERLINK http://www.aaos.org/wordhtml/papers/position/scolios.htm http://www.aaos.org/wordhtml/papers/position/scolios.htm,  HYPERLINK http://www.aaos.org/wordhtml/bulletin/feb00/ptvw.htm http://www.aaos.org/wordhtml/bulletin/feb00/ptvw.htm,  HYPERLINK http://danke.com/Orthodoc/scoliosis.html http://danke.com/Orthodoc/scoliosis.html,  HYPERLINK http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=262&topcategory=Spine http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=262&topcategory=Spine,  HYPERLINK http://www.pioneer.wnyric.org/board/Board_Policy/Students__7000_/Student_Physicals/Scoliosis_Screening/scoliosis_screening.html http://www.pioneer.wnyric.org/board/Board_Policy/Students__7000_/Student_Physicals/Scoliosis_Screening/scoliosis_screening.html,  HYPERLINK http://www.doctorgeorge.com/article.php?sid=723 http://www.doctorgeorge.com/article.php?sid=723,  HYPERLINK http://216.239.35.100/search?q=cache:v6G8utBbKn0C:www.monroe2boces.org/sshsc/Scoliosis%2520Guidelines.PDF+screening,+scoliosis&hl=nl http://216.239.35.100/search?q=cache:v6G8utBbKn0C:www.monroe2boces.org/sshsc/Scoliosis%2520Guidelines.PDF+screening,+scoliosis&hl=nl,  HYPERLINK http://www.health.gov/nhic/NHICScripts/Entry.cfm?HRCode=HR1986 http://www.health.gov/nhic/NHICScripts/Entry.cfm?HRCode=HR1986,  HYPERLINK http://www.ctfphc.org/Abstracts/Ch31abs.htm http://www.ctfphc.org/Abstracts/Ch31abs.htm ,  HYPERLINK http://ptglobal.net/ajp/caps464.html http://ptglobal.net/ajp/caps464.html,  HYPERLINK http://www.mindspring.com/~sandysimmons/scoliosis.html http://www.mindspring.com/~sandysimmons/scoliosis.html ,  HYPERLINK http://www.scoi.com/scoilio.htm http://www.scoi.com/scoilio.htm,  HYPERLINK http://www.theuniversityhospital.com/scoliosis/html/aboutscoliosis/index.htm http://www.theuniversityhospital.com/scoliosis/html/aboutscoliosis/index.htm,  HYPERLINK http://www.jdryerscoliosis.com/ http://www.jdryerscoliosis.com/,  HYPERLINK http://www.liv.ac.uk/HumanAnatomy/phd/bss/bss.html http://www.liv.ac.uk/HumanAnatomy/phd/bss/bss.html,  HYPERLINK http://www.med.jhu.edu/ais/ http://www.med.jhu.edu/ais/,  HYPERLINK http://orthopedics.about.com/blscoliosis.htm?once=true& http://orthopedics.about.com/blscoliosis.htm?once=true&,  HYPERLINK http://www.medmedia.com/o11/59.htm http://www.medmedia.com/o11/59.htm,  HYPERLINK http://www.kpvspines.com/ http://www.kpvspines.com/,  HYPERLINK http://www.orthopaedics-scoliosis.com/content/scoliosis_information.html http://www.orthopaedics-scoliosis.com/content/scoliosis_information.html,  HYPERLINK http://milwaukee.brace.nu/ http://milwaukee.brace.nu/,  HYPERLINK http://www.support4scoliosis.co.uk/ http://www.support4scoliosis.co.uk/,  HYPERLINK http://www.anr.org.uk/index.htm http://www.anr.org.uk/index.htm,  HYPERLINK http://www.orthospine.com/ http://www.orthospine.com/,  HYPERLINK http://www.vaterconnection.org/professional/scoliosis.htm http://www.vaterconnection.org/professional/scoliosis.htm,  HYPERLINK http://www.ndos.ox.ac.uk/pzs/Other_Documents/Review_Papers.html http://www.ndos.ox.ac.uk/pzs/Other_Documents/Review_Papers.html,  HYPERLINK http://www.espine.com/ http://www.espine.com/,  HYPERLINK http://www-medlib.med.utah.edu/scoliosis/index.html http://www-medlib.med.utah.edu/scoliosis/index.html,  HYPERLINK http://www.spinesolver.com/scoliosis.htm http://www.spinesolver.com/scoliosis.htm,  HYPERLINK http://www.healthmarque.com.au/ http://www.healthmarque.com.au/,  HYPERLINK http://www.scoliosiscare.org/ http://www.scoliosiscare.org/,  HYPERLINK http://www.scoliosiscorrection.com/scoliosis.html http://www.scoliosiscorrection.com/scoliosis.html,  HYPERLINK http://dynamicpm.com/scoliosis/ http://dynamicpm.com/scoliosis/,  HYPERLINK http://www.healthy.net/index.asp http://www.healthy.net/index.asp,  HYPERLINK http://mmae.iit.edu/scoliosis/ http://mmae.iit.edu/scoliosis/. Search in the Study landscape at Fontys and at NIWI: On 11-04-02 and 12-04-02 there was searched in different books and magazines concerning the subject idiopathic scoliosis in the Study landscape at Fontys. Two books about scoliosis were found, and the magazine of the Norwegian Physiotherapists (Fysioterapeuten) and Physical Therapy (American) were searched into. On 15-04-02 there was searched for different books at NIWI. Relevant information from both places was copied, and later assessed to decide for inclusion or exclusion. Use of literature references in included articles: The articles copied and included based on the criterias, were also used as a source to find additional information. These articles had to be ordered from NIWI through the Study landscape at Fontys at a later moment. Literature from other sources: When visiting Sofies Minde and Sint Maartenskliniek information was also collected. Mostly this information came in verbal form, but at Sint Maartenskliniek the project group also received additional information in form of a brochure and informative letters for the physiotherapist. Description of the mostly used databases: Medline Compiled by the US National Library of medicine and published on the Web by Community of science, Medline is the worlds most comprehensive source of life sciences and biomedical bibliographic information with abstracts. It contains nearly eleven million records from over 7300 different publications from 1965 until today. More than 50000 records are added every year. Standardised terminology is applied by indexers to a specific concept, and allows articles referring to the same concept to be identified by searching for a single subject term. Cinahl The CINAHL database is the authoritative source of information for the professional literature of nursing, allied health, biomedicine, and healthcare. For almost forty years the Cumulative Index to Nursing and allied Health Literature( print index has indexed English-language and selected foreign-language journals covering nursing and other specialised health care areas. The database also contains relevant materials from seventeen allied health disciplines, plus biomedicine, management, behavioural sciences, health sciences, librarianship, education, and consumer health. The CINAHL database offer references to books, book chapters, pamphlets, audiovisuals, dissertations, educational software, selected conference proceedings, standards of professional practice, nurse practice acts, critical paths, and research instruments. Doconline Today the collection consists of more than 6000 books, reports, and dissertations etc. The Centre subscribes to 200 national and international medical journals in the fields of allied health. The database contains at this moment more than 73000 articles and documents and is accessible with keywords that are special for the allied health professions. Taken together with the fact that Medline does not contain a lot of journals in the field of allied health (rehabilitation) it makes this database a useful complementary database that should be consulted by everybody involved in a (literature) research project. An English key-word list is available and the database can be consulted on line. Appendix 5: Overview of the analysed articles presented in the results A. Articles about diagnosis/screening: 1. A study of the diagnostic accuracy and reliability of the scoliometer and Adams forward bend test. 2. Screening for idiopathic scoliosis. 3. An evaluation of the Adams forward bend test and the scoliometer on a scoliosis school screening setting. 4. School screening for scoliosis. 5. The efficacy of school screening for scoliosis. B. Articles about treatment/prevention: 1. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. 2. A meta-analysis of the efficacy of non-operative treatments of idiopathic scoliosis. 3. Adolescent idiopathic scoliosis. The effect of brace treatment on the incidence of surgery. 4. Adolescent idiopathic scoliosis: Treatment with the Wilmington brace. 5. Effect of exercise, bracing and electrical surface stimulation on idiopathic scoliosis: a preliminary study. 6. Influence of an in-patient exercise program on scoliotic curve. 7. Treatment of idiopathic scoliosis with side-shift therapy: an initial comparison with a brace treatment historical cohort. Appendix 6: Figures for screening.  EMBED Word.Picture.8  Figure 1 (35) Adams forward bend test  Figure 2 (35) Adams forward bend test with Scoliometer  Figure 3 (33) Topography Asymmetry  Figure 4 (33) Topography Symmetrical Appendix 7: Braces, casts and traction. Passive correction; braces and casts: Braces are constructed of different materials such as leather, metal or plastic. They are constructed to be worn constantly or they may be removable. Usually, before the achieved correction, a cast can be applied and maximum passive correction of the scoliosis attempted. To do this gravity must be eliminated and the spine elongated. This can be done by placing the patient in the prone or supine position and applying simultaneous pelvic and cervical traction, which will elongate the spine and decrease the curve. This is more successful when the spine is flexible (1). Lateral correction is attempted by either localized pressure plates or by traction straps. Traction and lateral corrective forces are applied by casting the patient on a scoliosis frame. A favoured cast method has employed cutting a wedge in the cast on the convex side of the curve and approximating the segments with a turnbuckle (1). The advantages of passive correction with plaster are: Relatively low costs. Skin-tight correction is maximum and continuously applied. The disadvantages with a plaster cast correction are: Casts must be changed frequently. Treatment may continue for many years, thus casts must be worn for many years. Most casts cannot be removed at home. They deny the patient personal hygienic and athletic activities. The prolonged period of limited activity imposed by casting may lead to loss of muscle and ligamentous tone. A great loss of correction occurs when removing of the cast (1). Metal and leather moulded braces and cast-like moulded plastic splints function in the same manner as a plaster cast but permit removal for bathing and exercises (1). Traction: Traction has been used for centuries in treatment of scoliosis. Methods have included hanging, bed rest with horizontal traction, and preoperative traction before cast application. This latter method of traction is applied on a Risser type frame. Elongation is of temporary value. Different forms of traction are used in combination with braces or exercises (1). Cotrels Method: Cotrel combines the use of traction with exercises similar to those given to patients wearing the Milwaukee brace. It is known to have value when used preoperatively (1). It uses the principles of elongation, de-rotation and lateral flexion by spinal traction, exercise and body casts (40). Other traction methods include cephalo-pelvic traction and halo-pelvic traction (1). Traction has been shown to be of more use for larger scoliotic curvatures closer to 90, and especially above 100 (43). The adolescents with these magnitude curves of idiopathic scoliosis often undergo surgery, related to the big risk of cardio-pulmonary disorders. For this reason traction is not covered further here (44). The Milwaukee brace: Metal bars in the front and back of the brace extend the length of the torso and are attached to a form-fitting plastic pelvic girdle and to a throat mould or ring, which encircles the neck. Straps attached to the metal bars hold the pressure pads, which are precisely placed depending on the individuals curve pattern (45). The lateral pads tend to prevent further lateral curving and rotation by a restraining pressure. It is conceivable that these pads also exert corrective passive forces, but restraint of progression of curves is their more probable effect. Thus, all that can be expected from these pads is that they hold curves, not necessarily correct them (1). While the bars hold the body erect the neck ring keeps the head centred over the pelvis and the pads push against the curve. Everything works together to keep the body straight and to prevent progression of the curve while the patient is growing (1). The design allows controlled distraction between the pelvic girdle and the mandibulo-occipital assembly; thus the child is kept permanently stretched and the effect of gravity partially avoided (13). A well made and thus tolerated brace can and must be kept lengthened at frequent intervals. Unless the brace is distracted and the effect of gravity removed by the brace being kept elongated, no beneficial effect can be expected. Many users of the brace have been too tolerant and in consequence have found it valueless, but only because they did not use it to stretch the curve. The failure to use the brace effectively has also led to its use being discontinued. Most cases that fail to respond to Milwaukee brace treatment, and in general this treatment creates some difficulties when it comes to wearing the brace (illness, poor fit, sores or neglect) (13). The Milwaukee brace was first used to replace plaster casts after spinal fusion surgery and later it was used for the non-operative management of scoliosis and kyphosis (46). - The advantages of the Milwaukee brace are: The child is able to remove the brace for toilet and shower/bathing activities and for daily one-hour periods to permit exercise activities such as swimming. Lateral and rotatory deformities are actively corrected by performance of specific exercises within the brace that enhance the passive corrective forces of the brace pads. The brace permits almost unlimited activities, excluding only contact sports for the safety of other children and very active sports such as tumbling on a trampoline, horseback riding and strenuous gymnastics for the safety of the patient. Because of all the physical activities encouraged by in and out of the brace, muscle and ligamentous tone is maintained after the brace is ultimately removed (2). - The disadvantages of the Milwaukee brace are: The brace must be worn day and night (23 of 24 hours) until the full growth, as revealed by x-rays views, is achieved. This usually takes many years. The brace, which has some undesirable cosmetic features, must be acceptable to the patient for constant wearing. The patient must agree to daily exercises within the brace. Little correction can be promised or expected. Upon removal of the brace by gradual weaning, much of the correction is frequently lost, but the curve only reverts to its original degree. If originally the curve was minor and deformity minimal, treatment is obviously successful (1). The value of the Milwaukee brace lies primarily in maintenance of the current curve status and the prevention of further progression. Various authors have claimed correction of idiopathic scoliosis of both the lateral curve and rotational deformities; this correction is minimal and according to Cailliets personal observation not significant. Prevention of progression, however, of both lateral curving and especially rotational deformity is extremely desirable and justifies the use of the Milwaukee brace (1). The use of a Milwaukee brace in early minimal scoliosis ensures that the patient reaches adulthood with minimal cosmetic deformity and a straight, well-balanced spine with good muscle ligamentous tone (1). The prescription of the Milwaukee brace can be indicated in any early scoliosis that is in progressing and approaching 20 of curvature. Curves that exceed 50 are poor candidates for the Milwaukee brace unless merely preventing further progression of the curve is the treatment objective and the patient refuses other forms of correction. A curve of that magnitude (50) is difficult to fit, and since flexibility may be limited, correction is also limited. Pulmonary studies have revealed that the brace apparently results in some respiratory impairment during its wearing by patients with curves that exceed 50. Curves of that magnitude are best considered for surgical care. When the major curve is present in the lumbar area, the Milwaukee brace is markedly limited in its value. Since there are no skeletal points of compression or correction pressures, the brace is effective principally to elongate the spine and correct lumbar lordosis by pelvic tilting from the pelvic band or by distraction from the occipital pad. Exercises away from the posterolateral lumbar pad are of value. In upper thoracic curves, above T4 and T5, brace correction is also difficult since this portion of the spine is removed from direct corrective forces of the brace by the scapular tissues. Traction from the occipital pad has some limited benefit to these curves. Surgery is indicated when the upper thoracic curve progresses and threatens pulmonary or neurological embarrassment. Where there are rib angulations with potential deformity and curves associated with kyphosis of a significant degree the Milwaukee brace is very effective. Under these conditions, early application is encouraged since rib deformities can be better controlled than corrected. (1) Apart from the difficulties of its use which are in fact neither numerous nor hard to overcome, too long use of the brace may have an effect upon the teeth and facial bones. The localiser plaster used for correction has the same effect (13). The force of the Milwaukee brace is applied superiorly to the occiput and mandible. This vertical force is resolved in an arc about the lower cranium and mandible, thereby passing through multiple centres of growing bone. The net effect is compression of these growth centres. Clinically, this is seen as an alteration in the alignment of the teeth. Removal of these forces will correct the dental alignment of the teeth spontaneously (13). In later years the neck ring and chin rest have been substituted with a throat mould to avoid these deformities (47). A common problem in scoliosis is seen in the adolescent who develops the common thoracic idiopathic scoliosis at the age of 12 to 14 years. These children, almost always girls, may be in the last year or two of growth and if the curve is small the wearing of a Milwaukee brace past the age at which the growth ceases may allow fusion to be avoided and yet keep the curve small. When in a brace a curve may well decrease by 15 to 20, but tends to relapse to its pre-brace figure when the brace is finally removed. Edmonson and Moris found, in a small series, 1% improvement maintained in high thoracic curves, 15% in thoracic curves and 16% in lumbar curves. Thus if a late onset curve is acceptable when first seen and the child is nearing skeletal maturity, the Milwaukee brace is one acceptable method of treatment (13). A curve pattern, which is eminently suitable for treatment with the Milwaukee brace in adolescent, is the double curve, usually of idiopathic aetiology (13). The double curve type is well compensated and usually not discovered until the curves are of a considerable magnitude (43). Double curves most often start late in childhood and only a minority progress seriously. When they do progress, the greatest deformity is shortness of the trunk. Their curvatures and rotations, being on opposite sides, balance each other and the visible deformity is not obvious except on forward flexion. Spinal fusion undertaken to prevent the only significant deformity, shortness of trunk, is obviously ineffective, for by the very act of fusion growth is stopped in the fusion area. Correction and fusion cannot themselves eradicate or even sometimes alter the only other noticeable deformity, being rotation. Thus little is gained for the patient by surgery and as two curves have to be fused it is a major surgical undertaking, sometimes requiring a two-stage operation and involving the fusion of not less than 12 to 14 vertebrae. The advantages are small and operation is best avoided. A progressive double curve is therefore an excellent indication for the use of a Milwaukee brace until after growth has ceased. There is a very general acceptance of this view (13). In a study by Lonstein and Winter, the records and x-rays of 1020 patients treated with the Milwaukee brace were reviewed and compared with the findings of a study by Lonstein and Carlson, which documented patients at the same hospital who had not been braced but who had been followed for progression of the curve. This retrospective study showed that bracing is an effective treatment halting the progression of the curve in statistically significant numbers compared to those patients not treated (45,48). They also demonstrated that the risk for progression of the curve still during brace treatment could be present. The risk was not only determined by the curve magnitude but also dependent on factors like Risser sign, onset of menarche and curve location (49). The Boston brace: In the early seventies, Hall and Miller from Boston Childrens Hospital developed the most popular of the TLSO systems, the Boston brace. The Boston brace was the first brace to utilize symmetrical standardized modules eliminating the need for casting. It was also the brace used in the Scoliosis Research Societys bracing study (45). The Boston brace extends from below the breast to the beginning of the pelvic area in front and just below the scapulae to the middle of the buttocks in the back. It is designed to keep the lumbar area of the body in a flexed position by pushing the abdomen in and flattening the posterior lumbar contour. Pads are strategically placed to provide pressure to the curve, and areas of relief or voids are provided opposite the areas of pressure (45). (Appendix 8, figure 1.) Watts et al. reported that the final treatment result with the Boston brace was comparable with the treatment with the Milwaukee brace. Udens evaluation of the treatment with the Boston brace gave a mean curvature correction of idiopathic scoliosis of 41% compared with the treatment with the Milwaukee brace with only a mean curvature correction of 10%. The different treatments were done on 57 patients with the curvature apex between T7 and L3 (49). The Charleston bending brace: The Charleston Bending Brace was introduced in 1979, developed by Reed and Hooper, CPO (certified prosthetist/orthotist). This brace is worn only at night during sleep. It is moulded to conform to the patients body while she/he is bent towards the convexity of the curve, thus over-correcting the curve during the eight hours it is worn (45). (Appendix 8, figure 2.) A preliminary study and subsequent follow-up of those using the nighttime bending brace are encouraging, particularly for a single curve. Although the studies show no evidence of improved compliance the potential for a patient to wear a part time brace, especially while sleeping, rather than the usual full-time (22-23 hours) regiment is cited as an important benefit. At this time the scoliosis community awaits definitive long-term studies on the Charleston Bending brace, and on part-time bracing in general (45). The Charleston Bending brace was compared with the Boston brace in a study from 1996, presented for the Scoliosis Research Society. Patients with 25-35 single curves were followed in prevention of curve progression. The study revealed that the Boston brace was statistically more effective in treating larger curves of 36-45 and multiple curves. The Charleston Bending brace was only worn at night compared to the Boston brace worn full-time (18-23 hours) (46). Appendix 8:Figures for treatment.  EMBED Word.Picture.8  Figure 1 (46). The Boston brace. Anterior view.  Figure 2 (46). A patient fitted with the Charleston Bending brace.  EMBED Word.Picture.8  Figure 3 (13). The Milwaukee brace. Shown is the anterior and lateral aspect.  EMBED Word.Picture.8  Figure 4 (40). An example of exercise for a patient with adolescent idiopathic scoliosis. The patient tries to pull herself up without actually raising her seat, while breathing through the chest. Appendix 9: Tables used in Result - Screening Table 1 (37). Descriptive statistics for the scoliometer for examiners 1 and 2 (N=105) Mean () SD ()Range ()Thoracic spine Examiner 1 Examiner 2 Lumbar spine Examiner 1 Examiner2  6.3 6.1 4.3 5.5 5.5 5.6 3.6 4.5 0-28 0-30 0-14 0-20 Table 2 (37). Positive Adams test for examiner 1 and 2 (N=105) Thoracic spine (%)Lumbar spine (%)Examiner1 Examiner274.2 74.352.4 81.0 Table 3 (37). Crude sensitivity, specificity, and predictive value estimates (95% CI) of the scoliometer and Adams forward bend test for thoracic curves using the Cobb angle as a gold standard EstimateScoliometer [%(CI)]Adams Test [%(CI)] Sensitivity Specificity Positive predictive value Negative predictive value 71 (59.84) 83 (73.93) 80 (69.92) 75 (64.86) 92 (85.10) 60 (47.74) 70 (59.80) 80 (79.99) CI = confidence interval Table 4 (37). Crude sensitivity, specificity, and predictive value estimates (95% CI) of the scoliometer and Adams forward bend test for lumbar curves using the Cobb angle as a gold standard. EstimateScoliometer [%(CI)]Adams Test [%(CI)] Sensitivity Specificity Positive predictive value Negative predictive value 51 (47.55) 83 (74.93) 70 (54.95) 69 (59.80) 73 (60.86) 68 (57.80) 64 (49.79) 77 (66.89) CI = confidence interval Table 5 (37). Strata-specific sensitivity and specificity estimates (95% CI) of the scoliometer and Adams forward bend test for thoracic curves using the Cobb angle as a gold standard Scoliometer [%(CI)] Adams Test [%(CI)]SensitivitySpecificitySensitivitySpecificity Age Group <14 yr. e"14 yr. Gender Male Female Surgery Yes No 67 (35.89) 73 (41.91) 71 (44.89) 71 (43.89) 85 (66.94) 68(40.88) 86 (69.94) 82 (62.92) 83 (72.90) 83 (70.91) 65 (53.76) 83 (71.91) 89 (65.97) 94 (78.98) 90 (72.96) 93 (78.98) 95 (86.96) 92 (75.98) 70 (49.85) 55 (47.74) 69 (66.73) 59 (45.72) 59 (45.72) 50 (36.64)CI = confidence interval Table 6 (37). Strata-specific sensitivity and specificity estimates (95%CI) of the scoliometer and Adams forward bend test for lumbar curves using the Cobb angle as a gold standard. Scoliometer [%(CI)] Adams Test [%(CI)]SensitivitySpecificitySensitivitySpecificity Age Group <14 yr. e"14 yr. Gender Male Female Surgery Yes No 51 (23.77) 51 (23.79) 59 (29.83) 50 (24.76) 43 (32.55) 53 (25.80) 83 (68.92) 83 (68.92) 80 (63.90) 84 (81.92) 88 (85.91) 83 (72.91) 76 (49.91) 72 (45.89) 66 (41.85) 74 (51.89) 64 (45.80) 76 (52.80) 66(47.81) 70 (51.83) 75 (62.85) 67 (63.70) 79 (70.85) 68 (55.79)CI = confidence interval Table 7 (60). Classification table presenting the relative risk of demand for surgery in relation to screening. Demand for surgeryYesNoTotalScreeningNo20 4 2424 38 6244 42 86YesTotalOdds ratio 7.7, 99%confidence interval 1.6-36. Table 8 (60). Distribution of sex, brace type, initial skeletal maturity and initial curve magnitude. 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