In a rare event, the four leading orthopedic societies have aligned on a combined statement on early detection for scoliosis.
The American Academy of Orthopedic Surgeons (AAOS), Scoliosis Research Society (SRS), Pediatric Orthopedic Society of North America (POSNA), and American Academy of Pediatrics (AAP) believe that there are documented benefits for children of earlier detection and non-surgical management of adolescent idiopathic scoliosis (AIS), earlier identification of severe deformities that are surgically treated, and of incorporating screening of children for AIS by knowledgeable health care providers as a part of their care.
Richard Schwend, MD is here to explain all the latest developments of early detection and management of adolescent idiopathic scoliosis?
Screening for Early Detection and Treatment of Scoliosis
Featured Speaker:
Learn more about Richard M. Schwend, MD
Richard Schwend, MD, FAAP
Richard M. Schwend, MD is Director of the Orthopaedic Research Program at Children’s Mercy Kansas City; Chair, American Academy of Pediatrics, Section on Orthopaedics; and Clinical Professor Orthopaedic Surgery, University of Missouri-Kansas City School of Medicine and University of Kansas Medical Center. He received his medical degree from St. Louis University School of Medicine, St. Louis, MO and completed a pediatrics residency at Children’s Mercy Kansas City, Kansas City, MO and an orthopaedic surgery residency with the Harvard University Combined Orthopaedic Residency Program, Boston, MA where he served as chief resident, pediatric orthopaedic surgery, Harvard University, Children’s Hospital, Boston, MA. He completed a fellowship in pediatric orthopaedic and spine surgery at Harvard University, Children's Hospital, Boston, MA and is certified in both pediatrics and orthopaedic surgery. Dr. Schwend serves on various professional committees, including those with the Pediatric Orthopaedic Society of North American (POSNA), the Scoliosis Research Society (SRS), the American Academy of Orthopaedic Surgeons, the Irish American Orthopaedic Society and the American Academy of Pediatrics (AAP).Learn more about Richard M. Schwend, MD
Transcription:
Screening for Early Detection and Treatment of Scoliosis
Dr. Michael Smith (Host): Our topic today is screening for early detection and treatment of scoliosis. My guest is Richard Schwend. He is the Director of the Orthopedic Research Program at Children’s Mercy Kansas City. Dr. Schwend, welcome to the show.
Dr. Richard Schwend (Guest): Hi, Dr. Mike.
Dr. Smith: Let’s talk first about exactly how we’re defining adolescent idiopathic scoliosis.
Dr. Schwend: I think the name “adolescent idiopathic scoliosis” pretty much describes it. It’s a condition in adolesents. It comes when kids start to reach their growth spurt. “Idiopathic” means they really don’t know the cause of it although there is a lot of exciting research about some genetics associated with it. Scoliosis just means a deformity of the spine where there is a sideward bend and also a twist to the spine as well.
Dr. Smith: Who is mostly affected by AIS? Where is some of the research looking mostly into as a cause? Is there a genetic component to this that we’re looking at more or is there something else that you think is causing this?
Dr. Schwend: About 3% of children under 16 have adolescent idiopathic scoliosis. It is somewhat frequent in families. There is a genetic tendency. What I mean by that is, there is not just one specific gene, but they’re finding out that there are many, many genes that can be affected. For instance, one gene might send signals for muscle development and another gene might send signals for nerve or connective tissue development. All of these different genes can be affected in influencing how the child’s spine develops and grows. It’s a very complex system of how the body develops. That’s where I think most of the exciting research is happening.
Dr. Smith: We have that side of research going on looking at actual cause, the genetics but what about today and what are we doing for adolescents today with AIS? What research has been presented recently for early detection and management?
Dr. Schwend: With the management first, Children’s Mercy was involved in this National Institutes of Health funded study. It was a multi-center study. There were over 25 study sites in North America called the BrAIST Study. BrAIST means “Bracing for Adolescent Idiopathic Scoliosis Trial”. What that study did was it took some children with scoliosis - of course, with consent from the family and the child – put them in a brace for the treatment of their scoliosis. Then, some children were not treated to see if there was a difference in the actual use of the brace in stopping the scoliosis. Because of the number of centers that were involved, we were able to come up with a couple hundred children that participated. They were able to show that bracing is very effective, if you wear the brace.
Dr. Smith: Was the brace applied maybe in an earlier time setting than previous bracing? Is that really what we’re finding out? That once you see that – applying the brace – if the patient is compliant with wearing it, that that’s the positive result?
Dr. Schwend: What they found was the earlier you apply a brace – for instance, the smaller the curvature is – the brace tended to be more effective. Also, you had to have worn the brace a minimum number of hours. This is a plastic brace that fits under the arms and around the trunk. You needed to wear the brace at least about 12 hours a day and probably 15-18 hours was the ideal amount to wear the brace. The children would typically wear these at least a year, more likely about two to three years.
Dr. Smith: In this situation, we recognize now that the earlier the brace is used—and, of course, you have to have the compliance--the better the result, as we just stated. That means, though, we need to be detecting the AIS earlier if we’re going to be able to really use this kind of data. What are we doing in terms then of recognizing AIS in children earlier?
Dr. Schwend: That’s a very good question. I think a lot of it is awareness on the family’s part. If one of their adolescent children has a deformity or their spine doesn’t just quite look right, I think the most important thing is to have their primary care doctor evaluate the child because they’re trained to examine the child more specifically. Also, during school physicals and sports physicals, when the child comes in during the adolescent years, the primary care doctor or the pediatrician can actually look at the back have the child bend forward and if they see any kind of difference on one side or the other when they bend forward. Then, they can get an x-ray of the spine. If the x-ray shows scoliosis, then they can refer the child to an orthopedic surgeon that has an interest in scoliosis treatment. That’s a very effective way to get the treatment started early.
Dr. Smith: Which we now know is extremely important based on the research results from the BrAIST Study. Right? That early detection is key.
Dr. Schwend: Yes. The BrAIST Study showed that there is an effective treatment, you just have to start it at a time that is early enough in the scoliosis that the brace can make a difference. That’s why the early detection for the family but also the medical evaluation is also so important – whether the pediatrician or the family doctor’s office. We’re really encouraging that the physicians use screening of the spine as part of their overall health assessment.
Dr. Smith: Dr. Schwend, I’m going to read you a statement that I got from Children’s Mercy it says: “In a rare event, the four leading orthopedic societies have aligned on a combined statement on early detection for scoliosis.” Can you tell us about why these orthopedic societies came together and what this statement actually says?
Dr. Schwend: The reason they came together is there is a task force called “The United States Preventive Services Task Force”. In 2004, based on the literature at the time of 2004, they felt that scoliosis screening was not effective and, actually, it could be harmful because if you’re screening a lot of children, you’re getting a lot of x-rays and then you’re putting them in treatment that, at the time, wasn’t known to be effective. They thought that could be a lot of extra x-rays and overtreatment of children that may not benefit. The BrAIST Study was a very well done trial funded by the National Institutes of Health and that showed conclusively that early bracing is effective which also depended on early detection. These four societies felt that – these are the leading societies that deal with orthopedics in children – they felt that the evidence was fresh enough now and convincing enough now that the 2004 statements from The United States Preventive Services Task Force should be re-looked at. That’s why the four societies came up together and made a statement about recommending early detection and early treatment.
Dr. Smith: Those societies – The American Academy of Orthopedic Surgeons, Scoliosis Research Society, Pediatric Orthopedic Society of North America, and, of course, the American Academy of Pediatrics are the four groups that came together to make that statement. Give me the take home of all of this. How does the statement that they are developing – how is that going to affect the everyday family physician or pediatrician?
Dr. Schwend: Basically, the statement has five points. The first point is that there has been some convincing new evidence since the 2004 Task Force statement. They are just trying to draw attention to everybody that there is new convincing evidence. Based on that, they’re recommending that screening examinations of the spine be part of preventive care visits in physician’s offices. They’re recommending for girls at age 10 and at age 12 and boys, once at age 13 or 14--just to have their spine looked at as part of their routine health maintenance examinations. They wanted also to make sure that people are well trained in the method. The method of choice for screening is to have the child bend forward and there is a tool called a scoliometer that is actually a little device that can actually tell you how many degrees of elevation that one side of the chest has compared to the other. The recommendation is if that is seven degrees or greater those children should be referred to an orthopedic surgeon for further evaluation. That was the third point. The fourth point was that, nowadays, we’re really, really careful about using as low as reasonably achievable radiation. Radiographs should be done in a way that minimizes the amount of radiation exposure to the child. Of course, The Pediatric Radiology Society is very, very involved in developing recommendations for that. The fifth part of our statement is that we felt that bracing is an effective intervention and should be considered for children that have early scoliosis.
Dr. Smith: Just to summarize everything up, Dr. Schwend – early detection, early bracing. Obviously, we want to encourage compliance there and we could see many, many positive outcomes as a result, correct?
Dr. Schwend: Correct. Yes. I think the real take home message is early detection because there is effective early treatment now that’s not operative. The real ultimate goal of the brace is to prevent the progression of scoliosis to the point of needing surgery. Ultimately, even though we surgeons, we’d like to decrease the chance of a child having to have surgery.
Dr. Smith: Dr. Schwend, I want to thank you for all of the work that you’re doing at Children’s Mercy and I want to thank you for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information you can go to ChildrensMercy.org. That’s ChildrensMercy.org. I’m Dr. Michael Smith. Thanks for listening.
Screening for Early Detection and Treatment of Scoliosis
Dr. Michael Smith (Host): Our topic today is screening for early detection and treatment of scoliosis. My guest is Richard Schwend. He is the Director of the Orthopedic Research Program at Children’s Mercy Kansas City. Dr. Schwend, welcome to the show.
Dr. Richard Schwend (Guest): Hi, Dr. Mike.
Dr. Smith: Let’s talk first about exactly how we’re defining adolescent idiopathic scoliosis.
Dr. Schwend: I think the name “adolescent idiopathic scoliosis” pretty much describes it. It’s a condition in adolesents. It comes when kids start to reach their growth spurt. “Idiopathic” means they really don’t know the cause of it although there is a lot of exciting research about some genetics associated with it. Scoliosis just means a deformity of the spine where there is a sideward bend and also a twist to the spine as well.
Dr. Smith: Who is mostly affected by AIS? Where is some of the research looking mostly into as a cause? Is there a genetic component to this that we’re looking at more or is there something else that you think is causing this?
Dr. Schwend: About 3% of children under 16 have adolescent idiopathic scoliosis. It is somewhat frequent in families. There is a genetic tendency. What I mean by that is, there is not just one specific gene, but they’re finding out that there are many, many genes that can be affected. For instance, one gene might send signals for muscle development and another gene might send signals for nerve or connective tissue development. All of these different genes can be affected in influencing how the child’s spine develops and grows. It’s a very complex system of how the body develops. That’s where I think most of the exciting research is happening.
Dr. Smith: We have that side of research going on looking at actual cause, the genetics but what about today and what are we doing for adolescents today with AIS? What research has been presented recently for early detection and management?
Dr. Schwend: With the management first, Children’s Mercy was involved in this National Institutes of Health funded study. It was a multi-center study. There were over 25 study sites in North America called the BrAIST Study. BrAIST means “Bracing for Adolescent Idiopathic Scoliosis Trial”. What that study did was it took some children with scoliosis - of course, with consent from the family and the child – put them in a brace for the treatment of their scoliosis. Then, some children were not treated to see if there was a difference in the actual use of the brace in stopping the scoliosis. Because of the number of centers that were involved, we were able to come up with a couple hundred children that participated. They were able to show that bracing is very effective, if you wear the brace.
Dr. Smith: Was the brace applied maybe in an earlier time setting than previous bracing? Is that really what we’re finding out? That once you see that – applying the brace – if the patient is compliant with wearing it, that that’s the positive result?
Dr. Schwend: What they found was the earlier you apply a brace – for instance, the smaller the curvature is – the brace tended to be more effective. Also, you had to have worn the brace a minimum number of hours. This is a plastic brace that fits under the arms and around the trunk. You needed to wear the brace at least about 12 hours a day and probably 15-18 hours was the ideal amount to wear the brace. The children would typically wear these at least a year, more likely about two to three years.
Dr. Smith: In this situation, we recognize now that the earlier the brace is used—and, of course, you have to have the compliance--the better the result, as we just stated. That means, though, we need to be detecting the AIS earlier if we’re going to be able to really use this kind of data. What are we doing in terms then of recognizing AIS in children earlier?
Dr. Schwend: That’s a very good question. I think a lot of it is awareness on the family’s part. If one of their adolescent children has a deformity or their spine doesn’t just quite look right, I think the most important thing is to have their primary care doctor evaluate the child because they’re trained to examine the child more specifically. Also, during school physicals and sports physicals, when the child comes in during the adolescent years, the primary care doctor or the pediatrician can actually look at the back have the child bend forward and if they see any kind of difference on one side or the other when they bend forward. Then, they can get an x-ray of the spine. If the x-ray shows scoliosis, then they can refer the child to an orthopedic surgeon that has an interest in scoliosis treatment. That’s a very effective way to get the treatment started early.
Dr. Smith: Which we now know is extremely important based on the research results from the BrAIST Study. Right? That early detection is key.
Dr. Schwend: Yes. The BrAIST Study showed that there is an effective treatment, you just have to start it at a time that is early enough in the scoliosis that the brace can make a difference. That’s why the early detection for the family but also the medical evaluation is also so important – whether the pediatrician or the family doctor’s office. We’re really encouraging that the physicians use screening of the spine as part of their overall health assessment.
Dr. Smith: Dr. Schwend, I’m going to read you a statement that I got from Children’s Mercy it says: “In a rare event, the four leading orthopedic societies have aligned on a combined statement on early detection for scoliosis.” Can you tell us about why these orthopedic societies came together and what this statement actually says?
Dr. Schwend: The reason they came together is there is a task force called “The United States Preventive Services Task Force”. In 2004, based on the literature at the time of 2004, they felt that scoliosis screening was not effective and, actually, it could be harmful because if you’re screening a lot of children, you’re getting a lot of x-rays and then you’re putting them in treatment that, at the time, wasn’t known to be effective. They thought that could be a lot of extra x-rays and overtreatment of children that may not benefit. The BrAIST Study was a very well done trial funded by the National Institutes of Health and that showed conclusively that early bracing is effective which also depended on early detection. These four societies felt that – these are the leading societies that deal with orthopedics in children – they felt that the evidence was fresh enough now and convincing enough now that the 2004 statements from The United States Preventive Services Task Force should be re-looked at. That’s why the four societies came up together and made a statement about recommending early detection and early treatment.
Dr. Smith: Those societies – The American Academy of Orthopedic Surgeons, Scoliosis Research Society, Pediatric Orthopedic Society of North America, and, of course, the American Academy of Pediatrics are the four groups that came together to make that statement. Give me the take home of all of this. How does the statement that they are developing – how is that going to affect the everyday family physician or pediatrician?
Dr. Schwend: Basically, the statement has five points. The first point is that there has been some convincing new evidence since the 2004 Task Force statement. They are just trying to draw attention to everybody that there is new convincing evidence. Based on that, they’re recommending that screening examinations of the spine be part of preventive care visits in physician’s offices. They’re recommending for girls at age 10 and at age 12 and boys, once at age 13 or 14--just to have their spine looked at as part of their routine health maintenance examinations. They wanted also to make sure that people are well trained in the method. The method of choice for screening is to have the child bend forward and there is a tool called a scoliometer that is actually a little device that can actually tell you how many degrees of elevation that one side of the chest has compared to the other. The recommendation is if that is seven degrees or greater those children should be referred to an orthopedic surgeon for further evaluation. That was the third point. The fourth point was that, nowadays, we’re really, really careful about using as low as reasonably achievable radiation. Radiographs should be done in a way that minimizes the amount of radiation exposure to the child. Of course, The Pediatric Radiology Society is very, very involved in developing recommendations for that. The fifth part of our statement is that we felt that bracing is an effective intervention and should be considered for children that have early scoliosis.
Dr. Smith: Just to summarize everything up, Dr. Schwend – early detection, early bracing. Obviously, we want to encourage compliance there and we could see many, many positive outcomes as a result, correct?
Dr. Schwend: Correct. Yes. I think the real take home message is early detection because there is effective early treatment now that’s not operative. The real ultimate goal of the brace is to prevent the progression of scoliosis to the point of needing surgery. Ultimately, even though we surgeons, we’d like to decrease the chance of a child having to have surgery.
Dr. Smith: Dr. Schwend, I want to thank you for all of the work that you’re doing at Children’s Mercy and I want to thank you for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information you can go to ChildrensMercy.org. That’s ChildrensMercy.org. I’m Dr. Michael Smith. Thanks for listening.