The USPSTF has composed a draft statement recommending that idiopathic scoliosis screening (routine screening to look for scoliosis) be discontinued for children 10-18 years. This draft has been published solely for the purpose of receiving public input. That’s us. So let’s begin.
Important: this draft statement is open to public input through June 26, 2017, 8pm ET.
I have placed a few quotes below from the US task force draft statement. My thoughts follow and other evidence follow each quote. — Karena
USPSTF statement on benefit from screening:
“The USPSTF found no direct evidence regarding the effect of screening for adolescent idiopathic scoliosis on patient-centered health outcomes.”
Karena: In 2015, Spine, a peer-reviewed medical journal published this study: A population-based cohort study of 394,401 children followed for 10 years exhibits sustained effectiveness of scoliosis screening. Oddly, this study is also listed as a reference in the USPSTF’s draft statement. Here are the conclusions of that study:
“This report describes the first large population-based study with a long-term follow-up indicating that a scoliosis screening program can have sustained clinical effectiveness in identifying patients with adolescent idiopathic scoliosis needing clinical observation. As the prevalence of adolescent idiopathic scoliosis increases, scoliosis screening should be continued as a routine health service in schools or by general practitioners if there is no scoliosis screening policy.”–Fong Dy, Cheung KM, Wong YW, Wan YY, Lee CF Lam TP, Cheng JC, Ng BK, Luk KD.
USPSTF statement on harm from screening:“The USPSTF found no studies on the direct harms of screening, such as psychological harms or harms associated with confirmatory radiography. The USPSTF found inadequate evidence to determine the harms of treatment.”
Karena: Strongly agree. These initial screenings are not radiographs and therefore there is no harmful radiation associated with these tests.
USPSTF Statement on treatment:
“The USPSTF found inadequate evidence on the treatment of idiopathic scoliosis (Cobb angle <50° at diagnosis) in adolescents with exercise (two small studies) or surgery (no studies) or its effects on health outcomes or the degree of spinal curvature in childhood or adulthood.”
Karena: The 2011 SOSORT Guidelines (Society on Spinal Orthopaedic and Rehabilitation Treatment) Guidelines cite 41 studies on exercise for scoliosis. The USPSTF draft cites 2 studies on the exercise and scoliosis and states that those studies show that exercise is ineffective for managing scoliosis. Based on the 41 studies that SOSORT cites, recommendation #21-#33 from SOSORT are about the effective use of exercise for scoliosis. It reads:
Physiotherapeutic specific exercises to prevent scoliosis progression during growth–SOSORT:
#21: Physiotherapeutic Specific Exercises are recommended as the first step to treat idiopathic scoliosis to prevent/limit progression of the deformity and bracing.
USPSTF statement on scoliosis symptoms in youth: “Most Children and adolescents with scoliosis do not have symptoms.”
Karena: Strongly Disagree. Here is a link to a commonly used pediatric pain screening tool. In my experience, just using the word pain with a child puts us at a disadvantage of learning what is really going on with a child. In my experience, if I ask a child on their first visit if they have pain, they almost always say, “no.” But it almost always turns out to be a false “no.” They have no other experience than the experience they have with their spine and nothing to compare it to. In other words, they don’t know if they are in pain or not. Here are a couple of anecdotes for you from three children I have worked with recently.
Ashlyn: I worked with Ashlyn for about a total of 6 hours before I heard about her back pain. Her mother told me she was a dancer: “She loves to dance. Spends all her free time dancing.”
Karena: “I bet you miss dancing. Are you excited to go back to class when you get back home?”
Ashlyn: “No, I am taking the next 6 weeks off. My back just gets weird if I dance too much. So I usually alternate 6 weeks of dance with a 6 week break.”
Karena: But you told me when you first came in that you don’t have any pain.
Ashlyn: Well, I don’t. It just gets tight and aches. It feels tired.
Travis: I worked with Travis for about 14 hours total before I discovered his story. Travis is the star soccer player on his team. He came in for a session one day after a game.
Karena: Hey Travis! How’d the game go?
Travis: Awesome! We won!
Karena: Cool! You must have played the whole game then?
Travis: No, only about half.
Karena: Your team was doing so well that they didn’t need you?
Travis: No, sometimes my back stiffens and I just don’t feel like I can breathe.
Olivia: I worked with Olivia for almost a full year (45-50 hours total), before I heard this story:
Karena: So what’s happening with the school trip to DC?
Olivia: Uhhh, not a lot. I’m not going.
Karena: What? Why?
Olivia: They won’t let my mom go. So I’m not going.
Karena: But there will be other parents, right?
Olivia: Well, yeah, but my mom knows how to adjust my brace.
Olivia: And I can’t walk that far–I get too stiff. And I’ll need my mom to go back to the hotel room with me. The other parents will have to stay with the group.
So perhaps, when screening children, the question about pain needs to change. Maybe the questions could be:
- Do you ever find yourself not doing something that your friends are doing? (field trips, dance classes, water parks, sports) Why?
- Do you play sports? If not, Why?
- What’s your favorite sport? Why?
- Is there anything you wish you could do better in your sport?
Leaving a comment for the USPSTF on their draft statement.
Go here to see the draft
Click on Leave a Comment
Feel free to copy and paste my comments from below!
Page 1, Question 2: What information, if any, did you expect to find in this draft Recommendation Statement that was not included?
Karena’s Response: I would expect a more thorough review of available evidence. The draft cites 30 studies. The recent recommendations from SOSORT: Society of Spinal Orthopaedic and Rehabilitation Treatment cites 380 studies. For example, the draft cites two studies on the effectiveness of exercise for idiopathic adolescent scoliosis where the SOSORT studies cites 41 and makes 8 recommendations on the effectiveness of using exercise in treating idiopathic scoliosis.
Page 1, Question 3: Based on the evidence presented in this draft Recommendation Statement, do you believe that the USPSTF came to the right conclusions? Please provide additional evidence or viewpoints that you think should have been considered.
Karena’s response: The I recommendation by the USPSTF for scoliosis screening is unwarranted based on current evidence. Please consider the following:
#1: In a study that you cite, [Spine J. 2015 May 1;15(5):825-33. doi: 10.1016/j.spinee.2015.01.019. Epub 2015 Jan 20.], the conclusions are strongly in favor of scoliosis screening: “This report describes the first large population-based study with a long-term follow-up indicating that a scoliosis screening program can have sustained clinical effectiveness in identifying patients with adolescent idiopathic scoliosis needing clinical observation. As the prevalence of adolescent idiopathic scoliosis increases, scoliosis screening should be continued as a routine health service in schools or by general practitioners if there is no scoliosis screening policy.”
#2: The draft cites two studies for the effectiveness of exercise for treating idiopathic scoliosis. SOSORT (Scoeity of Spinal Orthopaedic and Rehabilitation Treatment, cites 41 studies in support of exercise and idiopathic scoliosis. Their recommendations 21-28, recommend specific exercise for the early intervention of idiopathic scoliosis. See recommendations here: https://scoliosisjournal.biomedcentral.com/articles/10.1186/1748-7161-7-3
#3: The draft states that children with scoliosis do not experience pain. While there needs to be further evidence, please consider this: Children with pain are frequently assessed using the Pediatric Pain Screening Tool (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504741/). Children who have no other experience may not be able to define their own pain. They may not know that a back isn’t supposed to be stiff, or keep them from playing sports or other activities that most children participate in. They only know by comparison. This comparison will only come as they grow older.