Assessing Knowledge of the Clinical Identification of Scoliosis
Faculty Information
Name:
Dr. Stephanie Ihnow
Email
ihnowsb@ortho.ufl.edu
Phone
(352) 273-7460
Faculty Department/Division
Orthopaedic Surgery
This project is primarily:
CQI
Research Project Description:
Background: Adolescent Idiopathic Scoliosis (AIS) is a spinal deformity that causes curvature and a three-dimensional rotation of the vertebrae. It is the most common pediatric spinal deformity, affecting about 3% of adolescents worldwide. It is characterized by two periods of rapid growth, with most patients experiencing curve progression in adolescence. Curve progression has been documented to affect girls worse than boys, but there is no significant difference regarding race. Internationally, the literature estimates a prevalence of about 2.5%.
The prevalence of AIS in athletes might be higher. In a 2022 meta-analysis, Mousavi et al. found the prevalence to be similar to or higher than seen in studies of the general population. Furthermore, a relationship was determined between level of play and prevalence of scoliosis. Recreational and elite athletes showed a high prevalence of 35% (95% CI: 24%-47%) and 27% (95% CI: 13%-27%) respectively. Competitive-level athletes showed a low prevalence at 0.05% (95% CI: 0.03%-0.08%). This indicates the possibility of a U-curve relationship between level of play and incidence of scoliosis.
If athletes are more likely to develop curve progression, it might be beneficial for ATs to be trained and equipped to detect AIS and identify appropriate referral options. Early detection is essential for preventing curve progression. Delayed detection can be harmful in two ways. Invasive treatment is required for both increased curve magnitude and increased skeletal maturity. Delaying detection leads to a greater curve magnitude and skeletal maturity upon diagnosis. However, early detection allows bracing as the primary method of treatment. In a retrospective study of 618 AIS patients, bracing was found to be effective in managing curves. However, bracing was only indicated for 17% of patients as 18% had curves beyond optimal range for bracing and 55% of patients were skeletally mature. For 54% of patients, curves were detected by themselves or family members, indicating a lack of effective screening. Furthermore, curves detected by patients or patient families were, on average, 7 degrees greater than curves detected by physicians. As a result, the authors concluded that most AIS patients present too late for effective management with bracing.
Per the National Athletic Trainers Association (NATA), comprehensive clinical examination of the spine is a required competency of a certified athletic trainer. However, there is a paucity of literature to indicate athletic trainers’ efficacy in detecting spinal curves, especially in the United States. An international literature search showed moderate evidence that athletic trainers are ineffective in detecting aberrant spinal curves. A survey sent to 223 physiotherapists (commonly considered an international term for a clinician similar to an athletic trainer) in South Africa indicated most physiotherapists have a poor understanding of AIS. Results showed that only 33.6% of therapists could correctly answer more than 50% of the questions regarding scoliosis. As a result, the authors concluded that the participants had a poor understanding of AIS diagnosis, which is a problem as they are often the first contact practitioners for patients.
Poor understanding of AIS by athletic trainers could stem from a didactic curriculum, experiential curriculum, or both. A report from Welch Bacon et al suggests that experiential learning is insufficient as AT students are not sufficiently exposed to scoliosis. The report is based on a review of clinical AT practices hosting students in the experiential learning phase. A total of 30,630 physical exams were examined from 338 practicing ATs. More than half of the diagnoses were categorized as affecting the lower body region, and more than 80% of cases occurred in university or secondary school settings. The authors concluded that AT students were not gaining experience in all the common clinical practice settings. As a result, students are not engaging in a diverse patient population leading to a lack of understanding of specific pathologies, including AIS.
This deficiency should be addressed as most ATs can effectively measure biomechanical conditions seen in AIS. However, they might have a poor understanding of the clinical significance of their measurements. In a prospective cohort of experienced physiotherapists, basic physiotherapeutic measurements regarding AIS detection were shown to be valid and reliable.
Study Aim: This study aims to assess athletic trainers’ perceived familiarity and comfortability with identifying scoliosis in an adolescent patient population. Additionally, this study will determine if ATs can identify scoliosis in patients with varying Cobb angles based on clinical photographs. We will evaluate competence in assessment based on athletic training educational background, years in clinical practice, advanced training/degree acquisition, and clinical specialty.
Hypothesis: There will be no difference in ATs ability to identify scoliosis based on the various personal and professional variables.
Methods: Participants will be required to complete a REDcap survey to assess their knowledge of AIS. The survey will take about 10 minutes. Comparisons will be made between predefined confounders: athletic training educational background, years in clinical practice, advanced training/degree acquisition, and clinical specialty.
Role of Medical Student:
- Help develop and validate survey
- Help with survey distribution
- Survey result analysis
- Abstract and manuscript preparation
- Expand the study idea to other medical professional groups
Funding: none currently
Relevant Publications:
Wise CA, Gao X, Shoemaker S, Gordon D, Herring JA. Understanding genetic factors in idiopathic scoliosis, a complex disease of childhood. Curr Genomics. 2008;9(1):51-59. doi:10.2174/138920208783884874. PMID: 19424484; PMCID: PMC2674301.
Karol LA, Johnston CE, Browne RH, Madison M. Progression of the curve in boys who have idiopathic scoliosis. J Bone Joint Surg Am. 1993;75(12):1804-1810. doi:10.2106/00004623-199312000-00010. PMID: 8258551.
Wong HK, Hui JH, Rajan U, Chia HP. Idiopathic scoliosis in Singapore schoolchildren: a prevalence study 15 years into the screening program. Spine. 2005;30(10):1188-1196. doi:10.1097/01.brs.0000162280.95076.bb. PMID: 15897834.
Herring JA, ed. Tachdjian’s Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children. 6th ed. 2-volume set. Philadelphia, PA: Elsevier; 2021:2184. ISBN: 978-0-323-56769-5.
Luk KD, Lee CF, Cheung KM, Cheng JC, Ng BK, Lam TP, Mak KH, Yip PS, Fong DY. Clinical effectiveness of school screening for adolescent idiopathic scoliosis: a large population-based retrospective cohort study. Spine. 2010;35(17):1607-1614. doi:10.1097/BRS.0b013e3181c7cb8c. PMID: 20453727.
Yawn BP, Yawn RA, Hodge D, Kurland M, Shaughnessy WJ, Ilstrup D, Jacobsen SJ. A population-based study of school scoliosis screening. JAMA. 1999;282(15):1427-1432. doi:10.1001/jama.282.15.1427. PMID: 10535432.
Mousavi L, Seidi F, Minoonejad H, Nikouei F. Prevalence of idiopathic scoliosis in athletes: A systematic review and meta-analysis. BMJ Open Sport Exerc Med. 2022;8(3). doi:10.1136/bmjsem-2022-001312
Anthony A, Zeller R, Evans C, Dermott JA. Adolescent idiopathic scoliosis detection and referral trends: Impact of treatment options. Spine Deform. 2021;9(1):75-84. doi:10.1007/s43390-020-00182-6
du Toit A, Tawa N, Leibbrandt DC, Bettany-Saltikov J, Louw QA. Current knowledge of idiopathic scoliosis among practising physiotherapists in South Africa. S Afr J Physiother. 2020;76(1):1500. doi:10.4102/sajp.v76i1.1500. PMID: 33241160; PMCID: PMC7669976.
Welch Bacon CE, Cavallario JM, Walker SE, Bay RC, Van Lunen BL. Characteristics of patient encounters for athletic training students during clinical education: A report from the Association for Athletic Training Education Research Network. J Athl Train. 2022;57(7):640-649. doi:10.4085/1062-6050-526-21
Lukovic T, Cukovic S, Lukovic V, Devedzic G, Djordjevic D. Towards a new protocol of scoliosis assessments and monitoring in clinical practice: A pilot study. J Back Musculoskelet Rehabil. 2015;28(4):721-730. doi:10.3233/BMR-140574. PMID: 25502347
Does this project have an international component or travel?
No