Screening and non-operative management of adolescent idiopathic scoliosis

Abstract

Idiopathic scoliosis is a common disease developed in adolescents. The prevalence of adolescent idiopathic scoliosis (AIS) varied in different regions. Diversified results of previous epidemiological studies on AIS were noticed in Mainland China. After a careful review of all the relevant studies, several studies were found to have substantial limitations. Based on the experience learned from previously published studies, the first part of my PhD project was a cross-sectional study determining the epidemiology of AIS based on a representative sample city, Wuxi (the east part of China), not only to overcome the limitations of previous studies, but to fill the epidemiological blank in this area since no large-scale study on the prevalence of AIS in this area has been performed. Primary and secondary school students aged 10-16 years were enrolled in this study. Physical examination and the Adam's forward bending test (FBT) combined with the Scoliometer were applied at school-based screening. Those who had angles of trunk inclination of 5° or more were referred for whole spine X-ray examination. The threshold for confirmed diagnosis was the Cobb angle of 10° or more. A total number of 79,122 students were screened. The overall prevalence of AIS in Wuxi City was estimated as 2.4%. Girls had higher overall prevalence (3.12% versus 2.14%) as well as higher prevalence in each age subgroup as compared to boys. Higher prevalence was found in individuals with lower body mass index (BMI). Mild and moderate curves were the most common types in this study. To conclude, the prevalence of AIS in this region was slightly higher. Medical resources should be considered for the children with lower BMI and high risk of scoliotic progression. Application of the Scoliometer would be suitable for mild to moderate scoliotic deformities while alternative methods should be developed for those with severe deformities or higher BMI. To the best of our knowledge, this study was the largest scoliosis school screening program ever conducted in the east part of China and filled the epidemiological blank of AIS in this region and may serve as the reference for future studies. Apart from that, longitudinal screening data are strongly suggested to collect, the effectiveness of the specific treatment can be partially reflected by the trend of the prevalence. A number of well-designed studies comparing non-operative management of AIS have been performed and the evidence becomes stronger. After a long period in which research on non-operative management of AIS continuously increased, the situation changed in the last 10 years. Nevertheless, there is a strong need to continue this research, recommendations also stress the need for high quality studies, not simply studies with low level of evidence, for searching the correct indications and contraindications. There is no high-level evidence supporting the effectiveness of orthotic intervention versus exercise. Based on the concerns mentioned above, a prospective randomized controlled trial (RCT) was planned right after the screening. Specifically, it was designed to investigate the effectiveness of orthotic intervention versus exercise on spinal curvature, body symmetry and quality of life (QoL). The inclusion criteria recommended by the Scoliosis Research Society (SRS) and the Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) were applied during enrollment. Eligible patients were randomly assigned to either the orthotic intervention group or the exercise group. Patients in the orthotic intervention group were prescribed with a rigid thoracolumbosacral orthosis (TLSO) and requested to wear 23h/day, while patients in the exercise group were treated with the protocol of the scientific exercises approach to scoliosis (SEAS). Data regarding angle of trunk inclination (ATI), Cobb angle, shoulder balance, body image, QoL were collected every 6 months. Twenty-four patients in the orthotic intervention group and 29 patients in the exercise group participated in this study. For the inter-group comparison, the orthotic intervention group showed better results about the correction of spinal curvature (5.88±6.37° in the orthotic intervention group vs. 2.24±3.19° in the exercise group, p=0.01). For scores concerning QoL, especially function (4.88±0.14 in the exercise group vs. 4.71±0.13 in the orthotic intervention group at the 12-month follow-up evaluation, p<0.001), mental health (4.48±0.20 in the exercise group vs. 4.18±0.25 in the orthotic intervention group at the 12-month follow-up evaluation, p<0.001) and total score (102.17±1.87 in the exercise group vs. 99.00±2.32 in the orthotic intervention group at the 12-month follow-up evaluation, p<0.001), were higher in the exercise group than that of the orthotic intervention group. The results of body symmetry evaluation did not differ significantly between the two groups. For the intra-group comparison, parameters of spinal curvature (baseline vs. 12-month, p<0.03 in the exercise group and p<0.001 in the orthotic intervention group), QoL (baseline vs. 12-month, p<0.001) and scores of the trunk appearance perception scale (TAPS) (baseline vs. 12-month, p<0.033) significantly improved over the studied period. Shoulder balance (baseline vs. 12-month, p<0.005) showed significant improvement only in the orthotic intervention group. To conclude, both interventions of orthotics and exercise showed significant treatment effectiveness on the patients with AIS. Orthotic treatment was superior to capture corrections in parameters of spinal curvature and body symmetry, while the QoL, especially in aspect of the functional and psychological status, was significantly better in the exercise group. Significant correlations were detected between the internal deformity (spinal deformity reflected by Cobb angle and trunk deformity reflected by shoulder balance) and the external deformity (body image evaluated by the TAPS). The dynamic changes of corresponding parameters due to the intervention were also significantly correlated. Although generally no significant correlation was detected between mental health and items representing deformity in this study, the total scores of SRS-22 and scores of satisfaction were significantly correlated with mental health. Finally, better compliance can lead to better treatment outcomes and in turn improve the satisfaction of the treatment, the latter would positively affect the compliance and the general QoL. In conclusion, both orthotic intervention and exercise showed significant treatment effectiveness on patients with AIS in this study and it was the first RCT study designed to answer the clinical question "Whether orthotic intervention and exercise are equally effective to the patients with mild to moderate AIS?". Although the short-term effectiveness of orthotic intervention versus exercise has been verified in the current study, it is strongly suggested that efforts should be donated to long-term RCTs with high quality according to the recommendations published by the SRS and the SOSORT though the difficulties in performing RCTs have generally reached a consensus.