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Evaluation of scoliosis screening at Simon Fraser Health District Wynne, Elizabeth Jean 1981

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EVALUATION  OF SCOLIOSIS SCREENING AT SIMON FRASER HEALTH DISTRICT by ELIZABETH JEAN WYNNE  B.Sc.N., The U n i v e r s i t y  of B r i t i s h Columbia,  1957  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (HEALTH SERVICES PLANNING) in THE FACULTY OF GRADUATE STUDIES Department of H e a l t h Care and Epidemiology  We a c c e p t t h i s  t h e s i s as conforming  to the r e q u i r e d  standard  THE UNIVERSITY OF BRITISH COLUMBIA October 1981  E l i z a b e t h Jean Wynne, 1981  In presenting  this thesis  i n partial  r e q u i r e m e n t s f o r an a d v a n c e d  degree  of  B r i t i s h Columbia, I agree that  it  freely available  fulfilment of the at the University  the Library  f o r r e f e r e n c e and study.  agree t h a t p e r m i s s i o n  s h a l l make I  further  f o rextensive copying of t h i s  thesis  f o r s c h o l a r l y p u r p o s e s may be g r a n t e d b y t h e h e a d o f my department  o r by h i s o r h e r r e p r e s e n t a t i v e s .  understood that for  copying o r p u b l i c a t i o n  f i n a n c i a l gain  shall  of this  ~lcL*-&-4-^CJt~  The U n i v e r s i t y o f B r i t i s h 2075 W e s b r o o k P l a c e V a n c o u v e r , Canada V6T 1W5  thesis  n o t be a l l o w e d w i t h o u t my  permission.  Department o f  It i s  (LA-AJL* CK^^A.  Columbia  written  ii  ABSTRACT  T h i s study  evaluates  s c o l i o s i s s c r e e n i n g c a r r i e d out by  Simon F r a s e r H e a l t h  D i s t r i c t among grade seven students  1976  The  to June 1980.  mine i f the evidence  the  from September  r e s u l t s o f s c r e e n i n g were reviewed t o d e t e r -  of f o u r y e a r s of s c r e e n i n g s u b s t a n t i a t e s the  t i n u a t i o n of the program.  The  program was  i n i t i a t e d with  the  con-  belief  t h a t d e t e c t i o n of s c o l i o s i s at an e a r l y stage would a l l o w b r a c i n g treatment as an a l t e r n a t i v e to major s p i n a l s u r g e r y scoliosis  curvatures.  The and  f o r c o r r e c t i o n of  c r i t e r i a f o r e v a l u a t i o n of s c r e e n i n g programs i n g e n e r a l  s p e c i f i c a l l y f o r s c o l i o s i s s c r e e n i n g were s e l e c t e d a f t e r a  of the l i t e r a t u r e .  Four p r i n c i p a l c r i t e r i a were u t i l i z e d  t h i s s c r e e n i n g program:  the a c c e p t a b i l i t y of the t e s t to the  c h i l d r e n and p h y s i c i a n s a f f e c t e d by s c r e e n i n g , the treatment, the v a l i d i t y of the t e s t and to c a r r y out  evaluate parents,  the a c c e p t a b i l i t y of  the a v a i l a b i l i t y of  resources  the program.  Class l i s t s , were sources  to  search  r e c o r d cards and  previous  r e p o r t s of the program  of data on the r e s u l t s of the s c r e e n i n g program.  t i o n a l data was  gathered  through q u e s t i o n n a i r e s  d u r i n g telephone  i n t e r v i e w s of p a r e n t s  and  s c r e e n i n g p o s i t i v e s i d e n t i f i e d from  the  to p h y s i c i a n s .  Outcomes of the 169 s c r e e n i n g p o p u l a t i o n of 8010  boys and g i r l s , p r i m a r i l y grade seven  s t u d e n t s , were examined and  i t was  f o r 167  screened  of the 169  Addi-  students  found t h a t r e s u l t s were a v a i l a b l e positive.  Of these, 40  (24  percent)  iii  were o r t h o p e d i c a l l y p o s i t i v e and  36 g i r l s  (curve over 10°by Cobb method), 4 boys  f o r a male t o female r a t i o o f 1:9.  A c t i v e treatment 12 c h i l d r e n , a l l female.  by b r a c e and/or s u r g e r y was recommended f o r There were t h r e e r e f u s a l s i n t h e n i n e  i n which b r a c i n g was recommended  cases  (33.3 p e r c e n t ) and t h r e e of the n i n e  c h i l d r e n f o r whom s u r g e r y was recommended a l s o r e f u s e d (33.3 p e r c e n t ) . Six  c h i l d r e n were b r a c e d , but t h r e e of these e v e n t u a l l y r e q u i r e d s u r g -  i c a l correction.  A t o t a l o f s i x c h i l d r e n had s p i n a l s u r g e r y .  Of the  38 curves f o r which X-ray i n f o r m a t i o n i s known, 25 were l e s s than 20° initially  and 13 were g r e a t e r than 20°.  under 20° r e q u i r e d  None of the curves  initially  treatment.  A f o u r f o l d t a b l e was p r e s e n t e d u s i n g an e s t i m a t e of s c o l i o s i s p r e v a l e n c e t o d e r i v e t o t a l d i s e a s e d i n the s c r e e n i n g p o p u l a t i o n . s i t i v i t y o f t h e s c r e e n i n g t e s t was e s t i m a t e d a t 26.2 p e r c e n t ,  Sen-  specifi-  c i t y a t 98.4 p e r c e n t , o v e r r e f e r r a l a t 75.1 p e r c e n t , u n d e r r e f e r r a l a t 1.5 p e r c e n t and t h e p o s i t i v e p r e d i c t i v e v a l u e a t 24.9 p e r c e n t . p r e d i c t i v e v a l i d i t y was 97 p e r c e n t .  Overall  P r e v a l e n c e o f s c o l i o s i s i n SFHD  was e s t i m a t e d a t 0.6 p e r c e n t compared t o p r e v a l e n c e r e p o r t e d i n the l i t e r a t u r e o f 2 p e r c e n t to 4 p e r c e n t i n s i m i l a r p o p u l a t i o n s u s i n g the same o r t h o p e d i c s t a n d a r d f o r a p o s i t i v e  curve.  Costs f o r the s c r e e n i n g program to the h e a l t h d i s t r i c t were approximately  $17,800 f o r f o u r y e a r s .  The c o s t s o f r e f e r r a l s e r v i c e s  e x c l u d i n g s u r g e r y f o r d i a g n o s t i c ( t r u e ) p o s i t i v e s were e s t i m a t e d a t $12,250 and c o s t s f o r the f a l s e p o s i t i v e s  (orthopedically  negative)  were $6,325. The  c o n c l u s i o n reached was t h a t although, s c o l i o s i s s c r e e n i n g  has had community acceptance,  t h e a c c e p t a b i l i t y of treatment  t i o n a b l e , the v a l i d i t y of the t e s t was n o t supported e r a b l e r e s o u r c e s were consumed.  was ques-  and t h a t c o n s i d -  The absence of a c e n t r a l  referral  c l i n i c was i d e n t i f i e d as a r e s o u r c e d e f i c i e n c y . I t was recommended health d i s t r i c t . ing  t h a t t h e program be d i s c o n t i n u e d a t t h i s  Furthermore i t was recommended t h a t s c o l i o s i s  screen-  n o t be i n t r o d u c e d to o t h e r areas of the p r o v i n c e because of the  difficulties  f o r s e e n i n o r t h o p e d i c e v a l u a t i o n and o r t h o t i c s e r v i c e , as  w e l l as because of doubts about v a l i d i t y of t h e t e s t and a c c e p t a b i l i t y of  treatment. Some s u g g e s t i o n s were made f o r m o d i f i c a t i o n s should t h e program  be continued  a t SFH.D and f o r f u t u r e s t u d i e s .  V  DEDICATION  To Tom, Mary and Andrew.  vi  TABLE OF CONTENTS  ABSTRACT  i i  DEDICATION  v  TABLE OF CONTENTS LIST OF TABLES  vi viii  LIST OF FIGURES  ix  ACKNOWLEDGEMENT  x  CHAPTER I .  1  INTRODUCTION  The H y p o t h e s i s  2  D e s c r i p t i o n of S c o l i o s i s  2  The  3  I m p l i c a t i o n s of S c r e e n i n g  S c o l i o s i s S c r e e n i n g a t Simon F r a s e r H e a l t h D i s t r i c t  5  O r g a n i z a t i o n of the T h e s i s  7  D e f i n i t i o n of Terms Used i n T h i s Study  8  CHAPTER I I .  REVIEW OF THE LITERATURE  E v a l u a t i o n of S c r e e n i n g Programs  11 11  Evaluation C r i t e r i a Applied to S c o l i o s i s and  Scoliosis  CHAPTER I I I .  Screening  22  METHODOLOGY  55  Purpose o f t h e Study  55  D e s c r i p t i o n o f the S c r e e n i n g Program  55  Study Method  59  vii  C a l c u l a t i o n of Resources Used  61  Methods of A n a l y s i n g Program Data . . . .  62  E t h i c a l Review  66  CHAPTER IV.  RESULTS OF THE SCREENING PROGRAM  A c c e p t a b i l i t y of the S c r e e n i n g  Test  67 67  A c c e p t a b i l i t y o f Treatment  70  V a l i d i t y of the Test  74  Availability  83  CHAPTER V.  of Resources  DISCUSSION  A p p l i c a t i o n o f General  94 Criteria  E v a l u a t i o n by P r i n c i p a l C r i t e r i a CHAPTER V I . General  CONCLUSION  Recommendations  Recommendations f o r F u r t h e r Study LIST OF REFERENCES  94 100 108 I l l 113 115  APPENDICES A.  I n t r o d u c t o r y L e t t e r t o Family  121  B.  I n t e r v i e w Format  123  C.  Consent f o r P h y s i c i a n Contact  126  D.  Introductory L e t t e r to P h y s i c i a n  128  E.  Questionnaire  130  F.  C e r t i f i c a t e of A p p r o v a l  133  G.  L e t t e r of P e r m i s s i o n  135  to P h y s i c i a n  viii  LIST OF TABLES  Table I.  II. III. IV. V. VI. VII. VIII.  IX. X. XI. XII.  XIII. XIV. XV.  Page DEATHS DUE TO SCOLIOSIS AND DUE TO ALL CAUSES B.C. AND CANADA, 1972-1978  27  REFUSAL OF CONSENT FOR SCREENING  68  TREATMENT OF ORTHOPEDIC POSITIVE CHILDREN  70  REFUSAL OF REFERRAL RECOMMENDATION  73  RESULTS OF SCOLIOSIS SCREENING 1976-1980 IN SFHD . . . .  74  SEX OF ORTHOPEDICALLY POSITIVE CASES .  76  FOURFOLD TABLE DERIVED USING PREVALENCE STATISTICS . . .  79  NUMBER AND RATE OF ORTHOPEDIC POSITIVES PER SCREENING YEAR  82  SFHD RESOURCES UTILIZED IN SCOLIOSIS SCREENING  84  NUMBER OF SERVICES PROVIDED FOR ORTHOPEDIC POSITIVES . .  86  NUMBER OF REFERRALS SEEN BY GENERAL PRACTITIONER AND ORTHOPEDIST AND X-RAY STATUS COST OF SERVICES PROVIDED FOR ORTHOPEDIC  87  POSITIVE SCREENEES  88  SERVICES PROVIDED FOR ORTHOPEDIC NEGATIVE SCREENEES  . .  90  COST OF SERVICES FOR ORTHOPEDIC NEGATIVE SCREENEES . . .  91  SURGERY WITH HARRINGTON ROD (ICD CODE 930.4) IN B.C. BY HOSPITAL APRIL 1, 1979 TO MARCH 31, 1980  93  LIST OF  FIGURES  Figure 1.  2.  Page F a c t o r s i n f l u e n c i n g the e f f e c t i v e n e s s s c r e e n i n g program Fourfold  of  a 18  table c l a s s i f y i n g participants  i n a screening  program  64  3.  A n a l y t i c a l d e r i v a t i o n of the  f o u r f o l d table  4.  P a t t e r n of p r o g r e s s of s c o l i o s i s curves from i n i t i a l to maximum curve  65  78  ACKNOWLEDGEMENT  T h i s study has been f a c i l i t a t e d by the encouragement and coopera t i o n o f t h e s t a f f o f Simon F r a s e r H e a l t h D i s t r i c t . i s extended to Dr. John B l a t h e r w i c k ,  A s p e c i a l thank you  D i r e c t o r , who endorsed t h i s program  e v a l u a t i o n , to p h y s i o t h e r a p i s t s June Moore and Ann Ryder, who shared t h e i r records  and e x p e r t i s e and to t h e c l e r i c a l s t a f f f o r t h e i r  able  a s s i s t a n c e i n t h e p r e p a r a t i o n and d i s t r i b u t i o n o f l e t t e r s o f i n t r o d u c - . t i o n and q u e s t i o n n a i r e s . I wish t o express a p p r e c i a t i o n to my t h e s i s committee - Dr. James Robinson, chairman, and Dr. Annette S t a r k and K i r s t e n Weber. Each has p r o v i d e d be  s p e c i a l a d v i c e and guidance to enable t h e t h e s i s t o  produced. Others i n the f i e l d , who have shared t h e i r s t u d i e s o f s c o l i o s i s  s c r e e n i n g programs, p a r t i c u l a r l y Dr. able assistance. stages  J . I . W i l l i a m s , were o f c o n s i d e r -  Dr. E r i c Holowaty p r o v i d e d  o f t h e study  advice  i n the p r e l i m i n a r y  proposal.  F i n a l l y I would be remiss i n t h i s acknowledgement i f I d i d not say a p a r t i c u l a r thank you t o the f a m i l i e s who so w i l l i n g l y  shared  i n f o r m a t i o n and f e e l i n g s about t h e s c o l i o s i s program w i t h me. p h y s i c i a n s o f the h e a l t h d i s t r i c t , p a r t i c u l a r l y Dr. M i c h a e l a l s o a great a s s i s t a n c e i n p r o v i d i n g n e c e s s a r y outcome data.  The  P i p e r , were  1  CHAPTER I  INTRODUCTION  Improved h e a l t h s t a t u s of i n d i v i d u a l s i n t h e community i s a primary g o a l f o r a l l workers i n the f i e l d  of p u b l i c h e a l t h .  s t a n d a r d s of e n v i r o n m e n t a l h e a l t h a r e achieved  As b a s i c  and communicable  diseases  c o n t r o l l e d i t i s l o g i c a l t h a t a t t e n t i o n i s f o c u s s i n g on p r e v e n t i o n of chronic d i s a b l i n g diseases.  Those that a f f e c t c h i l d r e n and a f f l i c t  l i f e l o n g d i s a b i l i t y a r e of s p e c i a l concern t o the community h e a l t h fessional.  S c o l i o s i s i s one such  Administrators decisions with  pro-  disease.  and p o l i c y - m a k e r s seek a f a c t u a l b a s i s f o r program  the r e a l i z a t i o n i t i s no l o n g e r a c c e p t a b l e  to " e y e b a l l "  the e f f e c t s of programs i n p u b l i c h e a l t h and m e d i c i n e and thereby judge their u t i l i t y  (Freeman 1978).  What i s b e i n g  sought a r e s y s t e m a t i c ,  r e p l i c a b l e and p r e c i s e assessments of both e s t a b l i s h e d and i n n o v a t i v e programs w i t h i n the h e a l t h c a r e f i e l d .  Unfortunately  most  preventive  s c r e e n i n g has been c a r r i e d out w i t h o u t evidence o f i t s h e a l t h  effective-  ness and i n some cases i n d i r e c t c o n t r a d i c t i o n t o the a v a i l a b l e evidence (Sackett  1975b). T h i s study proposes to e v a l u a t e  district  the e f f o r t s of a p u b l i c h e a l t h  t o f i n d cases of s c o l i o s i s e a r l y , t h a t i s , b e f o r e  clinically  evident,  so t h a t c o n s e r v a t i v e  health f o r adolescents  i n i t s community.  program has become an accepted  they were  treatment would l e a d t o b e t t e r There i s r e c o g n i t i o n t h a t  this  p a r t o f t h e p u b l i c h e a l t h d e l i v e r y system  2 i n Simon F r a s e r H e a l t h D i s t r i c t its  (SFHD) but a l s o t h a t the evidence  of  e f f e c t i v e n e s s should be examined.  The The h y p o t h e s i s proposed  Hypothesis i s t h a t e v a l u a t i o n of the r e s u l t s of  f o u r y e a r s of s c r e e n i n g f o r s c o l i o s i s a t SFHD w i l l the s c r e e n i n g program s h o u l d be c o n t i n u e d .  s u b s t a n t i a t e that  The p r i n c i p a l c r i t e r i a f o r  e v a l u a t i o n t h a t w i l l be a p p l i e d to the r e s u l t s of s c r e e n i n g a r e the a c c e p t a b i l i t y of the s c r e e n i n g t e s t , a c c e p t a b i l i t y of treatment  for  the d i s e a s e d e t e c t e d by s c r e e n i n g , the v a l i d i t y of the t e s t and  the  a v a i l a b i l i t y of r e s o u r c e s . C o n s i d e r a t i o n w i l l a l s o be g i v e n to whether the g o a l of the program has been met,  t h a t i s , whether e a r l y d e t e c t i o n of s c o l i o s i s  treatment w i t h the Milwaukee b r a c e has  e l i m i n a t e d the need f o r s u r g e r y  f o r s c o l i o s i s i n the screened p o p u l a t i o n . necessary  and  To t e s t the h y p o t h e s i s i t i s  to c o n s i d e r the use of s c r e e n i n g i n g e n e r a l and as r e l a t e d  the management of s c o l i o s i s  i n the community.  D e s c r i p t i o n of  Scoliosis  S c o l i o s i s i s a c o n d i t i o n i n which a l a t e r a l c u r v a t u r e of s p i n e develops The curve may  the  l e a d i n g to r o t a t i o n a l d e f o r m i t y of the v e r t e b r a e and p r o g r e s s and r e s u l t  of the h e a r t and  i n serious d i s a b i l i t y with  lungs and a shortened  lifespan.  ribs.  impairment  Scoliosis i s class-  i f i e d as n o n - s t r u c t u r a l ( r e v e r s i b l e ) and s t r u c t u r a l Idiopathic scoliosis  to  (Irreversible).  i s a type of s t r u c t u r a l s c o l i o s i s and accounts f o r  about 70 p e r c e n t of a l l cases of s c o l i o s i s  (Keim 1978).  While  i t may  occur i n i n f a n c y or the j u v e n i l e y e a r s i t i s most common i n a d o l e s c e n c e . The  cause i s unknown but a g e n e t i c f a c t o r appears  to be  present.  3 S c o l i o s i s has  a f f e c t e d mankind s i n c e the days of the Stone  E a r l y drawings on cave w a l l s and r e v e a l e d t h a t the d i s e a s e was 1978).  Hippocrates  evidence  i n s k e l e t a l remains have  p r e s e n t i n our e a r l i e s t a n c e s t o r s  Indeed treatment  medical p r a c t i t i o n e r s  of s c o l i o s i s has  throughout  brace a f t e r t r a c t i o n . 1800's as was  (Keim  used the Greek word " s k o l i o s i s " meaning crooked  h i s w r i t i n g s and d e s c r i b e s the use of f o r c e f u l mechanical the curves.  Age.  history.  E x e r c i s e s and  s u r g e r y f o l l o w e d by  s p i n a l f u s i o n f o r s c o l i o s i s was  gymnastics  means to t r e a t  i n t r i g u e d and  Pare i n 1550  performed i n 1914.  challenged  a p p l i e d an  were u t i l i z e d  the use of a hinged  in  frame.  iron  i n the The  first  Modern management  i n c l u d e s o b s e r v a t i o n of the curve w i t h b r a c i n g or s u r g i c a l treatment those curves which p r o g r e s s  The  of  to a s e r i o u s s t a g e .  I m p l i c a t i o n s of  Screening  To d i s c o v e r d i s e a s e a t the e a r l i e s t stage i n i t s n a t u r a l h i s t o r y when measures may  be a p p l i e d to a r r e s t i t s p r o g r e s s or e f f e c t a c u r e  enormous a p p e a l to the h e a l t h c a r e p r a c t i t i o n e r concerned p r e v a l e n c e o f c h r o n i c disease.:  about  has  the  S c r e e n i n g has h e l d promise as the r o u t e  to t h i s d i s c o v e r y f o r the p r o f e s s i o n a l s e e k i n g to use p r e v e n t i v e measures. The  g o a l of s c r e e n i n g i s to apply a simple maneuver to a p o p u l a t i o n f o r  the purpose of s e p a r a t i n g these a p p a r e n t l y w e l l i n d i v i d u a l s i n t o d i s t i n c t groups.  two  The d i v i s i o n i s based on the p r o b a b i l i t y of the p r e -  sence of d i s e a s e or of a p r e c u r s o r of the d i s e a s e .  The premise i s t h a t  e a r l y i n t e r v e n t i o n i n the " a t r i s k " or d i s e a s e d group w i l l r e s u l t i n improved outcome. S c r e e n i n g has been a c o n t r o v e r s i a l i s s u e i n r e c e n t y e a r s . has  clouded the m e r i t s of accepted maneuvers such as s c r e e n i n g f o r  Debate  4 c e r v i c a l cancer.  The  t i o n of c e r t a i n now  l a c k of randomized c l i n i c a l s t u d i e s at the  widespread s c r e e n i n g procedures has been viewed  a c r i t i c a l o m i s s i o n by s e v e r a l s c i e n t i s t s McKeown and Knox 1968;  Sackett  e s t a b l i s h e d by r e s e a r c h e r s programs has  evolved  Those who  incep-  1975a).  1971;  E v a l u a t i v e c r i t e r i a have been  as the i s s u e of a c c o u n t a b i l i t y f o r s c r e e n i n g  as a major  question  (Cochrane and H o l l a n d  as  concern.  the i n s t i t u t i o n of widespread s c r e e n i n g  with-  out v a l i d a t i o n of i t s e f f e c t i v e n e s s i n terms of improved h e a l t h , p o i n t out  the d i f f e r e n t r e s p o n s i b i l i t y g i v e n the p r o f e s s i o n a l who  As d i s t i n c t  from t h e r a p e u t i c m e d i c i n e , i n s c r e e n i n g  p r a c t i t i o n e r seeks out an a p p a r e n t l y  screens.  the h e a l t h  w e l l i n d i v i d u a l and  subjects  p e r s o n to a maneuver to d e t e c t unknown d i s e a s e or d i s a b i l i t y . a p e u t i c m e d i c i n e the i n d i v i d u a l seeks m e d i c a l symptoms or s i g n s of i l l n e s s and able current p r a c t i c e .  The  care  In t h e r -  a t t e n t i o n because of  expects a s s i s t a n c e i n terms of  p r a c t i t i o n e r of  that  reason-  screening  . . . should have c o n c l u s i v e evidence t h a t s c r e e n i n g can a l t e r the n a t u r a l h i s t o r y of d i s e a s e i n a s i g n i f i c a n t p o r t i o n of those screened. (Cochrane and H o l l a n d 1971) Of course  i t i s not s c r e e n i n g i t s e l f which can " a l t e r the n a t u r a l  h i s t o r y " but tial  the a p p l i c a t i o n of e f f e c t i v e i n t e r v e n t i o n s .  It is  essen-  t h a t s c r e e n i n g of a p r e s c r i p t i v e nature be proven to do more good  than harm.  T h i s means that t h e r e must be knowledge t h a t the  procedures which may than d e t r i m e n t  t i v e n e s s , he  r e s u l t from s c r e e n i n g w i l l be of g r e a t e r b e n e f i t  to the c l i e n t  As w e l l as  clinical  (Sackett  1975a).  the e t h i c a l concern of the p r a c t i t i o n e r about  i s r e q u i r e d to be  f i n a n c i a l l y accountable  or i n d i v i d u a l s f u n d i n g h i s p r a c t i c e or agency.  effec-  to the government  P r e v e n t i v e measures such  5  as s c r e e n i n g is  a r e sometimes c o n s i d e r e d  to be c o s t e f f e c t i v e ;  the premise  t h a t e a r l y treatment w i l l reduce t o t a l h e a l t h c a r e c o s t s .  In  British  Columbia the p r o p o r t i o n of the p r o v i n c i a l budget a l l o c a t e d to h e a l t h r i s e n annually  to i t s p r e s e n t  governmental e x p e n d i t u r e s . a l l o c a t i n g resources be most e f f e c t i v e . are  l e v e l of 1.975  There are p l a n s  b i l l i o n or 30 p e r c e n t  of a l l  to c o n t a i n r i s i n g c o s t s  Those making d e c i s i o n s w i t h i n the M i n i s t r y of  of  Health the  resources.  In t h i s context  of governmental and  the e f f e c t i v e n e s s of s c r e e n i n g s c o l i o s i s screening  by  to those programs which have shown themselves to  t h e r e f o r e c o n s i d e r i n g program e v a l u a t i o n as a means to choose  most e f f e c t i v e use  has  p r o f e s s i o n a l concern about  t h i s i n v e s t i g a t o r wishes to e v a l u a t e  program which began at SFHD i n 1976.  f o r the reasons g i v e n and  the  This i s timely  e s p e c i a l l y because s e v e r a l other  provincial  h e a l t h d i s t r i c t s are c o n s i d e r i n g i n t r o d u c i n g programs and would b e n e f i t from e v a l u a t i o n of the experience  S c o l i o s i s Screening  at SFHD.  a t Simon F r a s e r H e a l t h  Simon F r a s e r H e a l t h D i s t r i c t New  (SFHD) encompasses the C i t i e s  of  Westminster, P o r t Coquitlam, P o r t Moody, the M u n i c i p a l i t y of  Coquitlam, the V i l l a g e of B e l c a r r a and p o p u l a t i o n of about 140,000. area with  E l e c t o r a l A r e a B,  for a  total  I t i s p r i m a r i l y a middle c l a s s suburban  a l a r g e number of i t s w o r k f o r c e commuting to j o b s i n the  nearby c i t y of Vancouver. was  District  The  school population  26,643 as of September 30th, 1980.  the M i n i s t r y of H e a l t h Administrative Officer,  of the P r o v i n c e the H e a l t h  of the h e a l t h  district  It i s a health d i s t r i c t of B r i t i s h Columbia.  The  within Chief  D i s t r i c t Director i s responsible  to  6 the A s s i s t a n t Deputy M i n i s t e r of P r e v e n t i v e S e r v i c e s w i t h i n the M i n i s t r y of H e a l t h . The January 1976  impetus f o r i n s t i t u t i n g s c r e e n i n g f o r s c o l i o s i s at SFHD i n was  concern  about the number of major s u r g i c a l  performed i n r e c e n t y e a r s  to c o r r e c t s e v e r e s c o l i o t i c curves  people w i t h i n the d i s t r i c t . at l e a s t ten cases  Surgery was  i n the community.  procedures i n young  known to have been r e q u i r e d i n  An o r t h o p e d i c surgeon and  h e a l t h u n i t d i r e c t o r together with h e a l t h d i s t r i c t personnel a p i l o t p r o j e c t to examine s c h o o l c h i l d r e n to assess  the  planned  i f a school  i n g program c o u l d d e t e c t the d i s e a s e at an e a r l y stage.  screen-  From the  i n i t i a l p r o j e c t d i s t r i c t - w i d e s c r e e n i n g began i n September 1976. belief  The  was  . . . t h a t a s c r e e n i n g program i n the community would d i s c o v e r c h i l d r e n w i t h s i g n s of s c o l i o s i s w h i l e s t i l l growing, thus p e r m i t t i n g c o n s e r v a t i v e treatment w i t h the Milwaukee b r a c e . (SFHU Report 1977) Reports of e a r l i e r programs such as the s t a t e w i d e program i n Delaware suggested  t h a t s c r e e n i n g e l i m i n a t e d the need f o r s u r g e r y  ( L o n s t e i n et a l . 1976). had  The American Academy of O r t h o p e d i c  p u b l i s h e d i t s p o s i t i o n on s c o l i o s i s s c r e e n i n g i n 1974  Surgeons  as f o l l o w s  The American Academy of Orthopaedic Surgeons hereby g i v e s i t s o f f i c i a l recommendation to any program of r o u t i n e examination of s c h o o l c h i l d r e n f o r the d e t e c t i o n of s c o l i o s i s and o t h e r c r i p p l i n g s p i n e d e f o r m i t i e s . The Academy r e c o g n i z e s t h a t by e a r l y d e t e c t i o n more a p p r o p r i a t e treatment can be g i v e n and a b e t t e r t o t a l treatment of t h i s d i s a b l i n g h e a l t h problem can be c a r r i e d out. ( L o n s t e i n et a l . 1976, p. 52) In s p i t e of the endorsement of t h i s r e s p e c t e d body t h e r e were o t h e r views about the worth of s c o l i o s i s s c r e e n i n g . of the Canadian Task Force  In a 1980  considering P e r i o d i c Health  Report  Examinations,  7 the recommendation c o n c e r n i n g  s c o l i o s i s was  There i s no s c i e n t i f i c j u s t i f i c a t i o n f o r t h e view t h a t s c r e e n and/or c a s e f i n d i n g f o r S c o l i o s i s i s d i s t i n c t l y b e n e f i c i a l . U n t i l b e t t e r evidence i s e s t a b l i s h e d , s c r e e n i n g i n a p e r i o d i c h e a l t h examination should be conducted o n l y w i t h i n t h e context of an e v a l u a t i v e study. (Report of a Task Force C o n s i d e r i n g P e r i o d i c H e a l t h E x a m i n a t i o n 1980, p. 73) In l i g h t  of t h e d i v e r g e n t views on t h e v a l u e o f s c o l i o s i s  screen-  i n g i t appears t i m e l y to review the r e s u l t s of t h e program a t SFHD. e v a l u a t i o n has a l r e a d y been done.  Since  i n c e p t i o n of s c o l i o s i s  Some  screening  at SFHD there have been y e a r l y r e p o r t s of t h e a v a i l a b l e outcomes, however many p h y s i c i a n s who r e c e i v e d t h e r e f e r r a l s of s c r e e n i n g p o s i t i v e s reported  t h a t they would c o n t i n u e  come was n o t r e p o r t e d  t o f o l l o w t h e c h i l d b u t the f i n a l  to the h e a l t h d i s t r i c t .  spent by s t a f f was made i n a l l y e a r s also  An estimate  except 1978-79.  out-  of t h e time  Some c o s t s were  estimated. S m a l l s t u d i e s were done i n 1977 and 1978 by t h e h e a l t h u n i t to  e s t a b l i s h how the program was r e c e i v e d by the community.  A public health  nurse v i s i t e d a random sample of 31 f a m i l i e s who had a c h i l d screened as p o s i t i v e and the a s s i s t a n t m e d i c a l h e a l t h o f f i c e r v i s i t e d practitioners  to determine t h e i r r e a c t i o n t o t h e program.  10 g e n e r a l The g e n e r a l  c o n c l u s i o n reached was t h a t the program was w e l l r e c e i v e d . I n t h e absence o f a p r o s p e c t i v e  study i t i s by a s c e r t a i n i n g what  the outcomes have been from the s c r e e n i n g planning  program that the n e c e s s a r y  d e c i s i o n s can be made now about t h e f u t u r e of t h i s program and  about expansion of s c r e e n i n g  t o other h e a l t h  Organization The  f o l l o w i n g chapter  c r i t e r i a used t o e v a l u a t e  districts.  of t h e T h e s i s  w i l l review the l i t e r a t u r e t o o u t l i n e the  s c r e e n i n g programs.  Next, t h e l i t e r a t u r e on  8 s c o l i o s i s and s c o l i o s i s s c r e e n i n g w i l l be reviewed t o determine how t h e p r i n c i p a l c r i t e r i a have been met. Chapter t h r e e w i l l p r e s e n t  the methodology of t h i s study  i n c l u d e a d e s c r i p t i o n of the program under review able. and  The procedure u t i l i z e d  to analyse  t o gather  and o f the d a t a  and w i l l avail-  a d d i t i o n a l outcome i n f o r m a t i o n  the r e l e v a n t i n f o r m a t i o n w i l l be d i s c u s s e d .  In Chapter f o u r the r e s u l t s w i l l be presented t a b u l a r form by percentages,  i n n a r r a t i v e and  r a t e s and use o f the f o u r f o l d t a b l e .  Chapter f i v e w i l l c o n t a i n d i s c u s s i o n of the r e s u l t s i n terms of the c r i t e r i a s e l e c t e d : bility  of treatment,  a c c e p t a b i l i t y of the s c r e e n i n g t e s t ,  validity  of the t e s t and a v a i l a b i l i t y or r e s o u r c e s .  There w i l l be a b r i e f review u s i n g the other The  accepta-  criteria.  c o n c l u d i n g chapter w i l l summarize the p o s i t i o n of s c o l i o s i s  s c r e e n i n g i n terms of t h e chosen c r i t e r i a and make recommendations about the c o n t i n u a t i o n of the program a t SFHD.  Suggestions  f o r f u r t h e r study  w i l l a l s o be made.  D e f i n i t i o n of Terms Used i n T h i s Study A c c e p t a b i l i t y - the e x t e n t . t o which the v o l u n t e e r was w i l l i n g the s c r e e n i n g , which can be expressed  to undergo  i n terms of u t i l i z a t i o n ,  or n e g a t i v e l y , as a t t r i t i o n d u r i n g the program. B r a c i n g - an a p p l i c a t i o n of an o r t h o p e d i c a p p l i a n c e ( o r t h o s i s ) to c o r r e c t or m a i n t a i n  a s c o l i o t i c curve.  An example would be the Milwaukee  brace. Cobb method o f curve measurement - the method of measuring the s t r u c t u r a l curve of s c o l i o s i s i n which the upper and lower end v e r t e b r a e a r e  first  s e l e c t e d , p e r p e n d i c u l a r s to t h e i r t r a n s v e r s e axes a r e next  e r e c t e d , then the a n g l e of the curve i s measured a t t h e i r p o i n t intersection.  I t i s the method of measurement advocated  by  the  S c o l i o s i s Research S o c i e t y . E f f e c t i v e n e s s - the c h a r a c t e r i s t i c of a maneuver or treatment good than harm to i n d i v i d u a l s plus acceptance),  to whom i t i s o f f e r e d  doing more  (efficacy  the same as u s e f u l n e s s .  E f f i c a c y - the c h a r a c t e r i s t i c of a maneuver or treatment than harm t o those who  doing more good  f u l l y comply w i t h the treatment  or recom-  mendations . E f f i c i e n c y - the a t t r i b u t e of worthwhileness  - the b e s t use of r e s o u r c e s  f o r the e x p e n d i t u r e made. O b s e r v a t i o n - as i t p e r t a i n e d to an outcome of s c o l i o s i s s c r e e n i n g the process by which the p h y s i c i a n who p o s s i b l e s c o l i o s i s saw t i o n , w i t h or w i t h o u t  11°  received a r e f e r r a l for  a c h i l d r e g u l a r l y f o r p h y s i c a l examinaradiography.  O r t h o p e d i c p o s i t i v e - any s c o l i o t i c or which reached  was  curve g r e a t e r than 10°  initially  or more w h i l e under o b s e r v a t i o n .  Those  curves which were l a b e l l e d " s i g n i f i c a n t " or " a t r i s k " by o r t h o p e d i s t w i l l be c a l l e d p o s i t i v e u n t i l X-ray  an  results deter-  mine the degree of c u r v a t u r e . P r e d i c t i v e v a l u e - the a b i l i t y  of a t e s t to g i v e an a c c u r a t e measure.  When g i v e n as p o s i t i v e , i t i s the percentage as p o s i t i v e who  of those  identified  have the d i s e a s e , or i f n e g a t i v e , those  a r e c o r r e c t l y i d e n t i f i e d as d i s e a s e f r e e . v a l u e g i v e s the percentage  Total  who  predictive  c o r r e c t l y l a b e l l e d by the  test.  10  R e f e r r a l - those c h i l d r e n found w i t h a p o s i t i v e s i g n o f s c o l i o s i s on s c r e e n i n g f o r whom a l e t t e r medical  t o the parent was s e n t a d v i s i n g  consultation.  R e l i a b i l i t y - the a b i l i t y  to y i e l d  c o n s i s t e n t r e s u l t s i n repeated  trials  or when a d m i n i s t e r e d by d i f f e r e n t s c r e e n e r s . S c o l i o s i s - f o r the purpose of t h i s study, a d o l e s c e n t i d i o p a t h i c  scol-  i o s i s , d e s c r i b e d as a l a t e r a l c u r v a t u r e o f the s p i n e w i t h r o t a t i o n o f the s p i n a l column and r i b s ,  t h a t i s , w i t h demon-  strated structural features. S c r e e n i n g - the presumptive  i d e n t i f i c a t i o n of unrecognized disease or  d e f e c t by the a p p l i c a t i o n o f t e s t s , examinations  or o t h e r p r o -  cedures . Screening p o s i t i v e - a c h i l d S e n s i t i v i t y - the a b i l i t y  found  t o have a s i g n or s i g n s of s c o l i o s i s .  of a t e s t t o c l a s s i f y as p o s i t i v e those p e r -  sons w i t h the d i s e a s e . S p e c i f i c i t y - the a b i l i t y  of a t e s t t o c l a s s i f y as n e g a t i v e those  persons  f r e e of the d i s e a s e . Surgery - i n t h i s study any o p e r a t i o n performed  f o r c o r r e c t i o n of a  s c o l i o t i c c u r v e , u s u a l l y s p i n a l f u s i o n w i t h H a r r i n g t o n Rod ins trumentation. V a l i d i t y - t h e measure of the frequency w i t h which the r e s u l t of a t e s t i s confirmed by an a c c e p t a b l e d i a g n o s t i c procedure.  The a b i l i t y  of the t e s t to s e p a r a t e those who have the c o n d i t i o n from who do n o t .  those  CHAPTER  TWO  REVIEW OF THE LITERATURE  T h i s chapter screening  will first  review the l i t e r a t u r e on e v a l u a t i o n of  programs and second w i l l review what has been w r i t t e n about  s c o l i o s i s and s c r e e n i n g  programs i n r e s p e c t  to these e v a l u a t i v e  cri-  teria.  E v a l u a t i o n of S c r e e n i n g  Programs  S i n c e the 1950's i t has become i n c r e a s i n g l y popular and  p u b l i c h e a l t h agencies to i n s t i t u t e s c r e e n i n g  d i s e a s e a t an e a r l y , symptomless stage. apparently  healthy  programs to d e t e c t  T h i s d i s c o v e r y of d i s e a s e i n  i n d i v i d u a l s has the purpose of b r i n g i n g to m e d i c a l  c a r e i n d i v i d u a l s at an e a r l i e r and h o p e f u l l y more o p t i m a l disease  for medical  f o r s u c c e s s f u l treatment.  stage of  " S u c c e s s f u l " i m p l i e s that there  will  be l e s s d i s a b i l i t y or premature m o r t a l i t y from the d i s e a s e when i t i s discovered  and t r e a t e d e a r l y i n i t s n a t u r a l  course.  Researchers agree t h a t f o r e t h i c a l and economic as w e l l as s c i e n tific ing  reasons c e r t a i n c r i t e r i a or p r i n c i p l e s should be met b e f o r e  i s instituted.  screen  The f o l l o w i n g i s a review of the c r i t e r i a , which  have been s e t out as g u i d e l i n e s both b e f o r e  screening  to use i n the c o n t i n u i n g e v a l u a t i o n of s c r e e n i n g by the major papers on t h i s s u b j e c t i n E n g l i s h  i s i n s t i t u t e d and  programs i n p r a c t i c e ,  literature.  Acheson Reinke (1969) c i t e s the f i v e c r i t e r i a proposed by Acheson i n 1963 to use i n d e t e r m i n i n g which d i s e a s e s a r e s u i t a b l e f o r s c r e e n i n g . These c r i t e r i a were 1) Each d i s e a s e should occur f a i r l y f r e q u e n t l y i n . t h e p o p u l a t i o n under c o n s i d e r a t i o n . 2) A d i s e a s e should be dangerous to l i f e and cause e x c e s s i v e absence from work and/or d i s a b i l i t y . 3) A s i n g l e s i g n should c a r r y w i t h i t the h i g h p r o b a b i l i t y t h a t the d i s e a s e i s p r e s e n t . 4) E l i c i t i n g the s i g n s h o u l d be s i m p l e a n d economical the same time u n o b j e c t i o n a b l e t o the p a t i e n t . -  and a t  5) There s h o u l d be r e a s o n a b l e p r o s p e c t t h a t steps can be taken to cure t h e d i s e a s e or to prevent i t s p r o g r e s s i n g once the d i a g n o s i s has been made. These c r i t e r i a w h i l e u s e f u l l a c k p r e c i s i o n when they a r e a p p l i e d , for  example as t o what c o n s t i t u t e s " f a i r l y f r e q u e n t l y " or " e x c e s s i v e  absence".  More p r e c i s e c r i t e r i a which i n c o r p o r a t e d the c r i t e r i a o f  Acheson were proposed by W i l s o n and Jungner i n 1968.  W i l s o n and Jungner In a World H e a l t h O r g a n i z a t i o n p u b l i c a t i o n t e n b a s i c p r i n c i p l e s were enunciated  and i t was recommended  mass s c r e e n i n g was  t h a t these should be met b e f o r e  instituted.  1) The c o n d i t i o n should be an important h e a l t h problem. 2) There s h o u l d be an accepted recognized disease. 3) F a c i l i t i e s  treatment  f o r d i a g n o s i s and treatment  f o r patients with  should be a v a i l a b l e .  4) There should be a r e c o g n i z a b l e l a t e n t or e a r l y stage.  symptomatic  13 5) There should be a s u i t a b l e t e s t or examination. 6) The t e s t should be acceptable to the population. 7) The n a t u r a l h i s t o r y of t h i s c o n d i t i o n , i n c l u d i n g the development from l a t e n t to declared disease, should be adequately understood. 8) There should be an agreed upon p o l i c y on whom to treat as patients. 9) The cost of case-finding ( i n c l u d i n g diagnosis and treatment of p a t i e n t s diagnosed) should be economically balanced i n r e l a t i o n to p o s s i b l e expenditure on medical care as a whole. 10) Case-finding should be a continuing process and not a "once and for a l l " p r o j e c t . (Wilson and Jungner 1968, pp. 26-27) Wilson and Jungner suggest these p r i n c i p l e s are guides to p l a n ning case-finding so that the main goal of early disease d e t e c t i o n , that of f i n d i n g and t r e a t i n g those with previously unknown disease, while not harming people who are w e l l , i s achieved.  When evaluating screening  Wilson and Jungner say that two separate but i n t e r r e l a t e d aspects are considered.  F i r s t i s the evaluation of the screening t e s t and second,  the evaluation of the r e s u l t s .  I n both aspects there i s the need for a v  standard of c r i t e r i a . McKeown Thomas McKeown (1968) gave two major requirements  for screening:  the procedure i s e f f e c t i v e and i t makes more optimum use of l i m i t e d resources than the a l t e r n a t i v e s a v a i l a b l e .  The e t h i c a l d i f f e r e n c e s  between screening and normal medical p r a c t i c e were discussed by t h i s writer.  He concluded  that screening should not be undertaken unless  there i s proven medical b e n e f i t . The c r i t e r i a to be applied to screening f a l l i n t o two categories accordingly:  b i o l o g i c a l and economic.  14  Before  a s c r e e n i n g measure can be d e c l a r e d sound on b i o l o g i c a l grounds  the n a t u r a l h i s t o r y of the d i s e a s e must be known, i d e n t i f i c a t i o n must be p o s s i b l e a t an e a r l y stage o f the c o n d i t i o n and b e n e f i c i a l methods of treatment must be a v a i l a b l e .  F o r economic j u s t i f i c a t i o n t h e a s s u r -  ance must be g i v e n t h a t l i m i t e d r e s o u r c e s  a r e b e t t e r employed w i t h  this  measure than any competing one. McKeown o u t l i n e s a scheme f o r e v a l u a t i o n of s c r e e n i n g  procedures.  He begins w i t h d e f i n i t i o n of the problem and review of the p o s i t i o n before screening.  Next i s review of evidence  procedure i t s e l f w i t h i n two major d i v i s i o n s ;  concerning  the s c r e e n i n g  t h a t i s review of the e v i -  dence about the e f f e c t i v e n e s s f i r s t o f the d i a g n o s t i c methods and second, of the proposed treatment. bility,  E v i d e n c e i s assessed  i n terms of a p p l i c a -  e r r o r r a t e s , comparison to t r a d i t i o n a l methods, a v a i l a b i l i t y of  resources,  a c c e p t a b i l i t y and c o s t .  A f t e r the p r e c e d i n g  review i s accom-  p l i s h e d McKeown suggests t h a t a c o n c l u s i o n c o u l d be reached the s t a t e o f evidence u t i l i z e the evidence  on the problem as a whole.  concerning  T h i s c o n c l u s i o n would  on the n a t u r a l h i s t o r y of the d i s e a s e and the  e f f e c t s of the s c r e e n i n g i n terms of both d i a g n o s i s and treatment. L a s t l y , t h e r e would be comparison of a l t e r n a t i v e approaches to the problem i n terms of m e d i c a l  gains and l o s s e s and f i n a n c i a l c o s t s and g a i n s .  In c o n c l u s i o n p r o p o s a l s  f o r a c q u i r i n g f u r t h e r evidence  and f o r a p p l i c a -  t i o n s of t h e v a l i d a t e d s c r e e n i n g procedure complete the e v a l u a t i o n scheme.  Cochrane and H o l l a n d These w r i t e r s (1971) r e i t e r a t e d p o i n t s made by McKeown and emphasized the e t h i c a l c o n s i d e r a t i o n i n the i n t r o d u c t i o n of s c r e e n i n g programs.  The c a l l f o r c o n c l u s i v e evidence  that screening could  alter  15  the n a t u r a l h i s t o r y of the c o n d i t i o n i n a s i g n i f i c a n t p r o p o r t i o n of screened  r a i s e d the i s s u e of economic b e n e f i t .  makes i t worthwhile?  These authors  concluded  those  What y i e l d from s c r e e n i n g t h a t s c i e n t i f i c and  pos-  s i b l y f i n a n c i a l j u s t i f i c a t i o n i s required before introducing screening tests. The  d e c i s i o n about which d i s e a s e s j u s t i f y s c r e e n i n g r e s t s on  e v a l u a t i o n of the t e s t used to d e t e c t them.  The  Cochrane and H o l l a n d f o r v a l i d a t i n g  are:  1)  Simplicity  2)  Acceptability  3)  Accuracy  4)  Cost  5) P r e c i s i o n or 6)  Sensitivity  7)  Specificity  the t e s t  c r i t e r i a g i v e n by  repeatability  The  c h o i c e of t e s t w i l l be based on compromise because f u l f i l l m e n t  one  c o n d i t i o n may  be o f f s e t by another.  argue t h a t s c r e e n i n g procedures  In summary Cochrane and  are v a l i d a t e d by p o s i n g  Is the t e s t j u s t i f i e d , s c i e n t i f i c a l l y and r e s u l t i n g b e n e f i t to the community?  two  f i n a n c i a l l y by  of  Holland  questions: the  How e f f i c i e n t i s the proposed t e s t as a method of measurement? (Cochrane and H o l l a n d 1971)  Sackett David S a c k e t t  (1975b) adds p r e d i c t i v e power to the seven  proper-  t i e s of Cochrane and H o l l a n d used i n e v a l u a t i o n of a s c r e e n i n g measure and  emphasizes that the importance g i v e n to a p a r t i c u l a r p r o p e r t y  will  vary according  to the.purpose of a t e s t .  a c c e p t a b i l i t y and tivity  c o s t a r e important  the most important  He  states that  i n s c r e e n i n g but he g i v e s s e n s i -  r a n k i n g among p r o p e r t i e s of a t e s t used f o r  s c r e e n i n g because the consequences of m i s s i n g a case may costly"  ( S a c k e t t 1975b).  simplicity,  be " t r a g i c  As w e l l as t e c h n o l o g i c a l requirements as  terms these e i g h t p r o p e r t i e s , S a c k e t t requirements must be c o n s i d e r e d .  f e e l s c l i n i c a l and h e a l t h  and he  care  He poses s i x q u e s t i o n s :  1) Are s c r e e n i n g maneuvers a b l e to d e t e c t d i s e a s e which i s l i k e l y to have an important impact upon h e a l t h ? 2) W i l l the treatment of r i s k f a c t o r s have a major impact upon the subsequent development of d i s e a s e ? 3) What are the p r o s p e c t s t h a t p a t i e n t s w i l l comply w i t h t h e r a p e u t i c regimens i n i t i a t e d as a r e s u l t of s c r e e n i n g programs? 4) Do e x i s t i n g s c r e e n i n g programs r e a l l y a l t e r the outcomes of the t a r g e t d i s e a s e ? 5) Are we m i s l e d by the t r a d i t i o n a l methods used i n e v a l u a t i n g the c l i n i c a l e f f e c t i v e n e s s of e a r l y d e t e c t i o n programs? 6) Have we c o n s i d e r e d the e n t i r e range of p o s s i b l e e f f e c t s of s c r e e n i n g , l a b e l l i n g of i n d i v i d u a l s as d i s e a s e d and the long-term therapy. ( S a c k e t t 1975a, p. 42) These q u e s t i o n s were d i s c u s s e d at a meeting of the World O r g a n i z a t i o n i n 1971  and  Health  t r a n s l a t e d i n t o seven c r i t e r i a f o r e v a l u a t i n g  s c r e e n i n g programs: 1) S c r e e n i n g must l e a d to an improvement i n e n d - r e s u l t s ( d e f i n e d i n terms of m o r t a l i t y ; p h y s i c a l , s o c i a l , and emotional f u n c t i o n ; p a i n ; and s a t i s f a c t i o n ) among those i n whom e a r l y d i a g n o s i s i s achieved or i n the o t h e r members of the community. a) The therapy f o r the c o n d i t i o n must f a v o r a b l y a l t e r i t s n a t u r a l h i s t o r y , not simply by advancing.the p o i n t i n time at which d i a g n o s i s o c c u r s , but by improving s u r v i v a l , f u n c t i o n , or b o t h . The m o d i f i c a t i o n of " r i s k f a c t o r s " i s not s u f f i c i e n t evidence of e f f e c t i v e n e s s , nor i s the f a c t that the proposed therapy i s commonly accepted. Claims f o r t h e r a p e u t i c e f f e c t i v e n e s s must  17 w i t h s t a n d r i g o r o u s methodologic s c r u t i n y , and e x p e r i mental evidence, such as c o n t r o l l e d c l i n i c a l t r i a l s , i s a p r e r e q u i s i t e . The measurement of s u r v i v a l and other e n d - r e s u l t s must w i t h s t a n d e p i d e m i o l o g i c and b i o s t a t i s t i c a l scrutiny. b) A v a i l a b l e h e a l t h s e r v i c e s must be s u f f i c i e n t both to ensure d i a g n o s t i c c o n f i r m a t i o n among those whose s c r e e n i n g i s p o s i t i v e and to p r o v i d e long-term c a r e . c) Compliance among asymptomatic p a t i e n t s i n whom an e a r l y d i a g n o s i s has been achieved must be a t a l e v e l to be e f f e c t i v e i n a l t e r i n g the n a t u r a l h i s t o r y of the d i s e a s e i n question. d) The long-term b e n e f i c i a l e f f e c t s , i n terms of endr e s u l t s , must outweigh the long-term d e t r i m e n t a l e f f e c t s of the t h e r a p e u t i c regimen u t i l i z e d and the l a b e l i n g of an i n d i v i d u a l as d i s e a s e d or a t h i g h r i s k . 2) The e f f e c t i v e n e s s of p o t e n t i a l components of m u l t i p h a s i c s c r e e n i n g should be demonstrated i n d i v i d u a l l y p r i o r to t h e i r combination. 3) I f the b e n e f i t s of s c r e e n i n g accrue to the community a t l a r g e r a t h e r than, or i n a d d i t i o n t o , the i n d i v i d u a l i d e n t i f i e d (e.g. d i s e a s e c a r r i e r s , s p e c i f i c o c c u p a t i o n s ) , the community b e n e f i t claimed must w i t h s t a n d s c i e n t i f i c scrutiny. 4) The c o s t - b e n e f i t and c o s t - e f f e c t i v e n e s s c h a r a c t e r i s t i c s of mass s c r e e n i n g and long-term therapy must be known. T h i s knowledge i s c o n s i d e r e d e s s e n t i a l i n d e v e l o p i n g an approp r i a t e mix of d i a g n o s t i c and t h e r a p e u t i c s e r v i c e s i n the f a c e of f i n i t e manpower and f i n a n c i a l r e s o u r c e s . Therefore, a mechanism f o r the f o r m a l p e r i o d i c weighing of c o s t s a g a i n s t b e n e f i t s or e f f e c t i v e n e s s should c o n s t i t u t e a b a s i c component of the i n i t i a l s c r e e n i n g a c t i v i t i e s . 5) The burden of d i s a b i l i t y f o r t h e c o n d i t i o n i n q u e s t i o n ( i n terms of d i s e a s e frequency, d i s t r i b u t i o n , s e v e r i t y , and a l t e r n a t i v e approaches to i t s d e t e c t i o n and c o n t r o l ) must warrant a c t i o n . 6) The c o s t , s e n s i t i v i t y , s p e c i f i c i t y , and a c c e p t a b i l i t y of the s c r e e n i n g t e s t must be known, and i t should l e n d i t s e l f to the u t i l i z a t i o n p a t t e r n s of the t a r g e t p o p u l a t i o n . 7) I d e a l l y , an e s t i m a t e of the s o c i a l b e n e f i t of p r e v e n t i n g , a r r e s t i n g , o r c u r i n g the c o n d i t i o n i n q u e s t i o n should be known. ( S a c k e t t 1975a, pp. 49-50) Sackett  (1975b) suggests t h a t when these c r i t e r i a a r e a p p l i e d  to most p r e v e n t i v e s c r e e n i n g  t e s t s they a r e performed without  evidence  18 as to t h e i r h e a l t h  effectiveness.  He  comments that by  of u n t e s t e d or i n v a l i d programs long-term i l l  implementation  e f f e c t s may  be  encountered.  There i s damage to the c r e d i b i l i t y of the h e a l t h p r o f e s s i o n a l s , i n t o a l t e r n a t i v e approaches to d e t e c t i o n are d i s c o u r a g e d and wastage of  research  there  is  resources.  Chamberlain Chamberlain (1979) i n h i s approach to e v a l u a t i o n depicts Figure  s i x f a c t o r s which must be  considered.  of  screening  These are shown i n  1.  The  The  The  natural history of the d i s e a s e  v a l i d i t y of the  test  a c c e p t a b i l i t y of screening  The  The  effectiveness treatment  of  a c c e p t a b i l i t y of treatment  The a v a i l a b l e h e a l t h ' s e r v i c e resources  F i g . 1 . — F a c t o r s i n f l u e n c i n g the e f f e c t i v e n e s s of a s c r e e n i n g SOURCE:  programme.  J . Chamberlain. E v a l u a t i o n of S c r e e n i n g Procedures. In The Theory and P r a c t i c e of P u b l i c H e a l t h . E d i t e d by W. Hobson. New York: Oxford, 1979, p. 745.  19 Chamberlain b e l i e v e s t h a t the importance of n a t u r a l h i s t o r y i s Unless  i t i s know what the course of the d i s e a s e would be without  v e n t i o n , t h e r e cannot be e v a l u a t i o n of the maneuver under The b e s t way  clinical  trial.  term because they  He  suggests  Unless  be a disadvantage  The v a l i d i t y cificity. it  must be c o n s i d e r e d  i n the case of  the The  i n the e v a l u a t i o n of a  there i s compliance w i t h  then t h e r e i s l i t t l e  t h e r e may  the randomized  d i s e a s e s f o r which s c r e e n i n g i s suggested.  a c c e p t a b i l i t y of treatment p r e v e n t i v e measure.  early treat-  t h a t these t r i a l s are of n e c e s s i t y l o n g -  i n v o l v e l a r g e numbers of people  c h r o n i c , low p r e v a l e n c e  inter-  investigation.  to e v a l u a t e the e f f e c t i v e n e s s of s c r e e n i n g and  ment i n a l t e r i n g the n a t u r a l course of the c o n d i t i o n i s by  therapy  foremost.  the recommended  p o i n t i n d e t e c t i n g the c o n d i t i o n i n terms of a n x i e t y and  indeed  i n c r e a s e d absenteeism.  of the s c r e e n i n g t e s t i s measured by s e n s i t i v i t y and  I t i s obvious  t h a t a s c r e e n i n g t e s t i s not s a t i s f a c t o r y i f  a l l o w s a l a r g e number of d i s e a s e d people  i n c o r r e c t l y l a b e l s as d i s e a s e d The s c r e e n i n g test.must  spe-  those i n d i v i d u a l s who  be a c c e p t a b l e  ease or r e s o u r c e s w i l l be wasted. r e s o u r c e s , must be c o n s i d e r e d  to s l i p  The  to the people  are r e a l l y w e l l . at r i s k of the  last factor, availability  dis-  of  i n e v a l u a t i n g s c r e e n i n g because i t i s  p o i n t l e s s to b e g i n a s c r e e n i n g program w i t h o u t c a r r y out the program and  through or i f i t  the c a p a c i t y both  to do f u r t h e r d i a g n o s t i c t e s t s and  to  treatment  as r e q u i r e d . Chamberlain emphasizes the importance of the a d m i n i s t r a t o r  having  as complete i n f o r m a t i o n as p o s s i b l e so t h a t the b e s t p o s s i b l e d e c i s i o n s can be made about the a l l o c a t i o n of s c a r c e r e s o u r c e s c o n t r o l an important  i n an attempt to  d i s e a s e by means of s c r e e n i n g programs.  Because  the e f f e c t s of s c r e e n i n g are dependent on what can be done to improve p r o g n o s i s by  treatment,  Chamberlain s t r e s s e s that a r e s e a r c h  priority  s h o u l d be the study and development of e f f e c t i v e t h e r a p i e s .  P e r i o d i c H e a l t h Examination In 1980 Examination  a f e d e r a l l y appointed  The d e c i s i o n was  t h r e e s e t s of The  first  a b l e treatment q u e s t i o n was  made as to whether the c o n d i t i o n  examination, offered?  criteria.  s e t of c r i t e r i a judged  or p r e v e n t i v e measure.  asked:  peutic, instituted  the e f f e c t i v e n e s s of the  avail-  To measure e f f e c t i v e n e s s the  Does the a v a i l a b l e treatment,  p r e v e n t i v e or t h e r a -  as a r e s u l t of c a r r y i n g out the p e r i o d i c h e a l t h  do more good than harm to those p a t i e n t s to whom i t i s  The Task F o r c e i d e n t i f i e d  e f f e c t i v e n e s s was  p a r i s o n between times t h a t treatment v a l i d i t y was  t h r e e grades of v a l i d i t y .  demonstrated i n a randomized c l i n i c a l  l e v e l I I , either a well-designed  of  pre-  t r u l y p r e v e n t a b l e a f t e r j u d g i n g i t a c c o r d i n g to a standard which  applied  I,  Task F o r c e on the P e r i o d i c H e a l t h  r e p o r t e d i t s f i n d i n g s a f t e r r e v i e w i n g 100 p o t e n t i a l l y  ventable conditions. was  Report  In  trial.  level In  cohort or c a s e - c o n t r o l study or com-  and p l a c e s w i t h and without  treatment,  o r p r e v e n t i o n does more good than harm.  The  would show third  based on the o p i n i o n of r e s p e c t e d a u t h o r i t i e s who  d e s c r i p t i v e s t u d i e s , c l i n i c a l e x p e r i e n c e or r e p o r t s f o r t h e i r  level used  informa-  tion. The tially  second s e t of c r i t e r i a judged  ameliorable suffering.  on the i n d i v i d u a l and  Two  the impact  the c u r r e n t burden of  aspects were c o n s i d e r e d :  on s o c i e t y .  For the  poten-  the  individual,  impact  21 measures such as l i f e years l o s t , m o r b i d i t y  i n terms of h o s p i t a l days,  p a i n , and treatment c o s t s were i n d i c a t o r s o f impact.  The impact on  s o c i e t y was determined by i n d i c a t o r s such as m o r t a l i t y , m o r b i d i t y and c o s t s of treatment. The  t h i r d and l a s t s e t of c r i t e r i a f o r j u d g i n g whether the con-  d i t i o n was p o t e n t i a l l y p r e v e n t a b l e  a p p l i e d to the maneuver undertaken  to f i n d or p r e v e n t the c o n d i t i o n .  Aspects considered  c r i t e r i a were the b e n e f i t s and r i s k s ; p r e d i c t i v e value; and  these  the s e n s i t i v i t y , s p e c i f i c i t y and  and the s a f e t y , s i m p l i c i t y , a c c e p t a b i l i t y to p a t i e n t s  cost. Following  t e r i a , prevention recommendation. to the s t r e n g t h  assessment of e v i d e n c e u s i n g  these t h r e e s e t s of c r i -  of the c o n d i t i o n would r e c e i v e one of f i v e c l a s s e s of These recommendations were l a b e l l e d A t o E  of the evidence t o i n c l u d e s c r e e n i n g  in  a p e r i o d i c h e a l t h examination (A) or t o e x c l u d i n g  C,  i n which s c o l i o s i s was p l a c e d ,  for  i n applying  according  f o r the c o n d i t i o n i t (E).  Category  s t a t e d t h a t t h e r e i s poor evidence  i n c l u s i o n or e x c l u s i o n of the c o n d i t ion  i n the p e r i o d i c h e a l t h  examination and posed the most d i f f i c u l t y f o r t h e committee.  The com-  m i t t e e suggested i n cases of inadequate evidence i t was b e t t e r t o e r r on the s i d e o f prudence and not i n c l u d e the c o n d i t i o n i n a p e r i o d i c health  examination.  Summary of C r i t e r i a Reviewing the c r i t e r i a p r e s e n t e d i t i s obvious t h a t there i s general  agreement on a core o f c r i t e r i a .  I t i s basic that  screening  must make a d i f f e r e n c e , and a p o s i t i v e d i f f e r e n c e , that i s , i t must do  22  more good than harm.  To know t h a t i s happening, the course  d i s e a s e must be understood. t a b l e to the c l i e n t .  The t e s t i t s e l f must be v a l i d and accep-  E f f e c t i v e treatment which i s a c c e p t a b l e must be  p o s s i b l e and the r e s o u r c e s  f o r d i a g n o s i s and treatment a v a i l a b l e .  these c r i t e r i a a r e met, economical review should the p a r t i c u l a r d i s e a s e r e p r e s e n t s compared  premise t h a t the evidence  presented  Underlying  After  show t h a t s c r e e n i n g f o r  a worthwhile use of f i n i t e  to o t h e r a l t e r n a t i v e uses.  scientifically,  of the  resources  a l l c r i t e r i a i s the  to meet the c r i t e r i a has been d e r i v e d  p r e f e r a b l y using experimental  or a t l e a s t  quasi-experi-  mental methodology. T h i s completes the review of c r i t e r i a proposed f o r e v a l u a t i o n of s c r e e n i n g .  I n the next s e c t i o n the l i t e r a t u r e on s c o l i o s i s and i t s  s c r e e n i n g programs a r e examined to determine how been  these c r i t e r i a  have  filled.  E v a l u a t i o n C r i t e r i a A p p l i e d to S c o l i o s i s and S c o l i o s i s S c r e e n i n g While t h e r e has been a g r e a t d e a l w r i t t e n about s c o l i o s i s and a c t i v e encouragement by the S c o l i o s i s Research S o c i e t y f o r s c r e e n i n g programs to be i n c l u d e d i n s c h o o l h e a l t h programs, e v a l u a t i v e s t u d i e s on the e f f i c a c y and e f f e c t i v e n e s s of t h i s s c r e e n i n g a r e r a r e . a f t e r a l i t e r a t u r e s e a r c h concluded  t h a t " t o date, no c r i t i c a l  t i o n s have been performed on any p u b l i s h e d p. 73).  Wingate evalua-  s c o l i o s i s programs" (1977,  The r a t i o n a l e f o r i n t r o d u c t i o n of s c r e e n i n g programs i s the  reportedly high prevalence treatment.  r a t e s of s c o l i o s i s and the b e n e f i t of e a r l y  No v a l i d a t i o n of the t e s t procedure, nor any estimates  of  the c o s t s , b e n e f i t s or e f f e c t i v e n e s s had been r e p o r t e d a t the time of Wingate's p u b l i c a t i o n .  23 H o w e l l (1978) i n Edmonton and W i l l i a m s and have p r e s e n t e d  T i c e (1980) i n O n t a r i o  r e s e a r c h f i n d i n g s i n r e c e n t years which attempt to e v a l -  u a t e s c r e e n i n g programs i n p l a c e i n those p r o v i n c e s .  They c a l l a t t e n t i o n  to s e v e r a l concerns about the e f f e c t i v e n e s s of s c o l i o s i s s c r e e n i n g of s c h o o l c h i l d r e n i n t h e i r j u r i s d i c t i o n s w i t h p a r t i c u l a r concern about r e l i a b i l i t y and v a l i d i t y of the s c r e e n i n g  the  test.  To u t i l i z e c r i t e r i a f o r e v a l u a t i o n of s c o l i o s i s s c r e e n i n g  pro-  grams as d e s c r i b e d i n the l i t e r a t u r e i t appears u s e f u l to b e g i n w i t h t e n c r i t e r i a d e f i n e d by W i l s o n and  Jungner i n 1968.  (1979) and Wingate (1977) have a l s o u t i l i z e d  screening  ( S a c k e t t 1975a) so t h a t twelve  V e r r i e r et a l .  t h i s framework.  t i o n a l c r i t e r i a have been s e l e c t e d from the 1971  the  WHO  Two  statement  addi-  on  c r i t e r i a i n a l l w i l l be  uti-  lized.  1.  The  c o n d i t i o n s h o u l d be an important Although  s c o l i o s i s has been known f o r c e n t u r i e s the  f o r c o n s i d e r a t i o n now concern  h e a l t h problem  i s - how  significant i s scoliosis?  i s the importance of a d o l e s c e n t  and  particular  i d i o p a t h i c s c o l i o s i s which  been the t a r g e t of SFHD's s c r e e n i n g program. the p r e v a l e n c e  Of  question  To e v a l u a t e  e f f e c t s of the d i s e a s e w i l l be  has  importance  discussed.  Prevalence Moe  e t a l . (1978) suggest  that prevalence  i s determined by mass  s c r e e n i n g techniques  a p p l i e d to l a r g e u n s e l e c t e d p o p u l a t i o n groups.  S c o l i o s i s prevalence  i n f o r m a t i o n i s a v a i l a b l e from two major  The  first  sources.  i s based on c h e s t X-rays taken f o r t u b e r c u l o s i s s c r e e n i n g  the second from s c h o o l s c r e e n i n g programs.  and  24  TB X-rays p r o v i d e d e a r l y i n f o r m a t i o n on the p r e v a l e n c e of iosis.  scol-  In a study of 50,000 m i n i f i l m s taken i n TB s u r v e y s , i n those  over 14 years of age s c o l i o s i s curves of 10° or more were noted i n p e r c e n t and 1955). (Moe  curves of 20° or more i n 0.5  Other  percent  s t u d i e s r e p o r t p r e v a l e n c e of 1.1  et a l . 1978)  respectively.  1.9  (Shands and E i s b e r g  p e r c e n t and  The disadvantages  0.47  of d a t a from  percent chest  m i n i f i l m s a r e the s m a l l s i z e of the f i l m , u n d e r p e n e t r a t i o n of the s p i n e and  the f a c t t h a t v i s u a l i z a t i o n of the lumbar s p i n e i s not i n c l u d e d . S c h o o l s c r e e n i n g programs have p r o v i d e d d a t a s i n c e programs  began, i n the s t a t e of Delaware i n 1962.  While  prevalence studies vary  t h e r e i s g e n e r a l agreement t h a t curves 11° or g r e a t e r a r e p r e s e n t i n 2 p e r c e n t to 4 p e r c e n t of young a d o l e s c e n t s (Brooks Howell  et a l . 1980;  Kane:.1977a;-."Moe e t a l . 1978;  L o n s t e i n (1977) reviewed  1980;  23 p r e v a l e n c e s t u d i e s from 1957  some v a r i a b i l i t y  recording a positive, p e r c e n t and  1977;  R o g a l i e t a l . 1978).  i n c l u d e d over a m i l l i o n s u b j e c t s from around the w o r l d . t h a t w h i l e t h e r e was  Hornung  to 1976 He  i n ages screened and  which  reported c r i t e r i a for  the p r e v a l e n c e r a t e g e n e r a l l y f e l l between  2.5  4 percent.  Kane (1977b) comments on the danger of the o v e r s t a t e d case i n r e g a r d s to p u b l i s h e d p r e v a l e n c e f i g u r e s from s c o l i o s i s s c r e e n i n g s t u d i e s . He notes  the c o n s i s t e n c y of f i g u r e s improves as the s e v e r i t y of  increases. distribution  He  suggests  t h a t a curve can be drawn based  (the n a t u r a l l o g of the number of degrees  i s normally d i s t r i b u t e d ) .  0.1  p e r c e n t f o r 40°  on a l o g normal of a c u r v a t u r e  From t h i s curve p r e v a l e n c e f i g u r e s of  p e r c e n t f o r 20° or g r e a t e r c u r v e s , 0.2  curve  0.5  p e r c e n t f o r 30° or g r e a t e r and  curves can be e s t i m a t e d .  Kane suggests  t h a t by  25  u s i n g two c r i t e r i a , f i r s t ,  t h a t s c o l i o s i s of 20° i n an immature p e r s o n  s h o u l d be t r e a t e d and second,  t h a t any immature i n d i v i d u a l w i t h a curve  over 10° should be f o l l o w e d , t h a t the a d o l e s c e n t s c o l i o s i s p o p u l a t i o n is  2.5 p e r c e n t .  Of the p o p u l a t i o n screened  for scoliosis  to be consensus on the p r e v a l e n c e o f t r e a t a b l e c u r v e s . (1978) suggests  there  appears  Rogala e t a l .  0.275 p e r c e n t and L o n s t e i n (1977) 0.3 p e r c e n t .  The H e a l t h S u r v e i l l a n c e R e g i s t r y can p r o v i d e p r e v a l e n c e  figures  f o r s c o l i o s i s by age-group and sex f o r B r i t i s h Columbia b u t i t i s acknowledged t h a t t h e r e has not been comprehensive r e p o r t i n g so t h a t the f i g u r e s do n o t r e f l e c t  the t r u e p r e v a l e n c e of s c o l i o s i s  P r e v a l e n c e by sex has been s t u d i e d e x t e n s i v e l y . s c o l i o s i s was f e l t  (Colls  1981).  Originally  t o be f a r more p r e v a l e n t i n females b u t the o c c u r -  r e n c e of minor curves i s d i s t r i b u t e d  i n a female  ( L o n s t e i n 1977) or 1.24:1 (Rogala e t a l . 1978).  to male r a t i o of 1.5:1 Rogala  found  the r a t i o  v a r i e d w i t h the s e v e r i t y of the c u r v e ; 1:1 f o r curves 6° to 10° and up to 5.4:1 f o r curves over 20°. ment.  The r a t i o was 7:1 f o r curves under  Keim (1978) r e p o r t s a 7:1 i n c i d e n c e o f p e r s i s t e n t  treat-  curves.  I n the o n l y study r e p o r t i n g p r e v a l e n c e by r a c i a l group S e g i l i n Johannesburg, South A f r i c a found  2.5 p e r c e n t of the Caucasians had curves  of 10° or more (N = 929) and A f r i c a n s (N = 1016) had a p r e v a l e n c e of 0.03 p e r c e n t  ( L o n s t e i n 1977).  There appears Rogala  found  t o be a f a m i l i a l tendency  for scoliosis  to occur.  a p o s i t i v e f a m i l y h i s t o r y i n 19 p e r c e n t of the s u b j e c t s i n  a study c a r r i e d out by h i m s e l f and o t h e r s i n 1978. In summary i t c o u l d be s t a t e d t h a t s c o l i o s i s i s a d i s e a s e of low p r e v a l e n c e and t h a t females w i t h a f a m i l y h i s t o r y of s c o l i o s i s a r e the most a t r i s k f o r s i g n i f i c a n t  curves.  26  E f f e c t s of s c o l i o s i s The but  c u r v a t u r e of the s p i n e i n s c o l i o s i s may be  those few curves which p r o g r e s s  1978).  The d e v e l o p i n g  non-progressive  can have s e r i o u s e f f e c t s  (Kane  c u r v a t u r e i s accompanied by s p i n a l column r o t a -  t i o n c a u s i n g f a n n i n g of t h e r i b s on one s i d e and inward compression on the o t h e r .  T h i s d i s t o r t i o n r e s u l t s i n cramping of the h e a r t and l u n g s .  Less m o b i l i t y of the s p i n e and a d i s f i g u r i n g r i b hump a r e o t h e r untoward effects. While t h e r e a r e many s t u d i e s of the p r e v a l e n c e  of s c o l i o s i s i n  the a d o l e s c e n t p o p u l a t i o n t h e r e i s a l a c k o f s t u d i e s i n d i c a t i n g the p o p u l a t i o n p r e v a l e n c e o f severe symptomatic s c o l i o s i s . document t h e death,  d i s a b i l i t y , d i s r u p t i o n , d i s c o n t e n t and d i s s a t i s -  f a c t i o n due t o s c o l i o s i s a r e r a r e . about 2 p e r c e n t 10°,  S t u d i e s which  While i t may be u s e f u l to note that  of an e a r l y a d o l e s c e n t  group have curves  greater  than  t o c o n s i d e r the importance of s c o l i o s i s f u r t h e r i n f o r m a t i o n i s  vital. S t a t i s t i c s c i t i n g s c o l i o s i s as a cause of death a r e a v a i l a b l e from S t a t i s t i c s Canada and a r e p r e s e n t e d  i n Table I .  K y p h o s c o l i o t i c h e a r t d i s e a s e which was mentioned by Nachemson (1968) as a l e a d i n g cause of death i n s c o l i o t i c s , claimed no l i v e s i n B.C.  in. 1979. and. caused o n l y t h r e e deaths i n Canada. L i m i t e d i n f o r m a t i o n i s a v a i l a b l e from case s t u d i e s which r e p o r t  the long-term  e f f e c t s of p r o g r e s s i v e s c o l i o t i c curves.  I t has been on  the b a s i s of these r e t r o s p e c t i v e s t u d i e s that the importance o f prevent i o n of s c o l i o s i s has been based.  TABLE I DEATHS DUE TO SCOLIOSIS* AND DUE TO ALL CAUSES, B.C. AND CANADA, 1972-1978  CANADA  B.C.  Total : Scoliosis  Total a l l causes  M  F  Total Scoliosis  Total a l l causes  M  F  1972  0  0  0  18021  0  3  3  162413  1973  0  1  1  18095  1  4  5  164039  1974  0  0  0  19177  0  1  1  166794  1975  0  1  1  19151  0  3  3  167404  1976  0  0  0  18788  1  3  4  167009  1977  0  0  0  18596  1  4  5  167498  1978  0  0  0  19058  2  1  3  168945  *ICD code 735.0 SOURCE:  Suzanne Draper, I n q u i r i e s Vancouver, B.C.  Officer,  S t a t i s t i c s Canada ( P e r s o n a l Communication, Aug. 12, 1981)  In a b r i e f r e p o r t of a study by Drummond et a l . (1976) l o n g term e f f e c t s of u n t r e a t e d s c o l i o s i s were c i t e d . by 40 p e r c e n t of the p a t i e n t s and the sample.  In t h i s study group:  t h i s was  Back p a i n was  c o n s t a n t i n 24 p e r c e n t  20% avoided s o c i a l c o n t a c t .  u n s e l e c t e d s e r i e s of 107 hospitals.  The  their  T h i r t y p e r c e n t of the men  cent of the women were unmarried.  of  24 p e r c e n t were unemployed, 15  cent had never worked, 69 p e r c e n t were embarrassed by and  reported  The  sample was  per-  appearance and  42  per-  of 55 a d u l t s from an  p a t i e n t s seen as c h i l d r e n i n t h r e e Quebec  degree of c u r v a t u r e however i s not r e p o r t e d .  F u r t h e r d e s c r i p t i o n s of persons  with untreated s c o l i o s i s  r e t r o s p e c t i v e s t u d i e s are r e p o r t e d under c r i t e r i a seven, the n a t u r a l h i s t o r y .  The r e p o r t e d p h y s i c a l and  from  concerning  s o c i a l e f f e c t s of  u n t r e a t e d p r o g r e s s i v e s c o l i o s i s would .appear to i n d i c a t e a s e r i o u s h e a l t h problem i n those persons  a f f e c t e d w i t h severe d i s e a s e but  mation i s l a c k i n g r e l a t i n g degree of c u r v a t u r e to e f f e c t s and v a l e n c e i n the p o p u l a t i o n .  Statements t h a t s c o l i o s i s i s an  h e a l t h problem must be c o n s i d e r e d as  2. There should be accepted disease  to p r e important  presumptive.  treatment  W i l s o n and Jungner c a l l t h i s  infor-  for patients with  the most important  recognized  criterion  because i t i s of paramount importance to t r e a t the c o n d i t i o n adequately when i t i s d i s c o v e r e d .  In the sense t h a t " a c c e p t e d "  c r i t e r i o n other w r i t e r s , such as Chamberlain and "effective".  E f f e c t i v e implies e f f i c a c y ,  i s used i n t h i s  S a c k e t t , use  t h a t i s , t h a t the  does more good than harm i n those r e c e i v i n g i t .  the term treatment  S a c k e t t suggests  w e l l as e f f i c a c y , e f f e c t i v e n e s s i n c l u d e s acceptance  as  of the treatment  by  those to whom i t i s o f f e r e d w h i l e Chamberlain separate c r i t e r i a . treatments  l i s t s a c c e p t a b i l i t y as a  Both e f f i c a c y and a c c e p t a b i l i t y of the r e c o g n i z e d  f o r s c o l i o s i s w i l l be d i s c u s s e d under t h i s  The  S c o l i o s i s Research  criteria.  S o c i e t y has p u b l i s h e d a P h y s i c i a n ' s  Handbook of S p i n a l S c r e e n i n g and Treatment which c o n t a i n s the recommended treatment  f o r s c o l i o s i s i n t h r e e major c a t e g o r i e s :  o b s e r v a t i o n , b r a c i n g and s u r g e r y . p e r i o d i c c l i n i c a l examinations  Controlled observation includes  w i t h s t a n d i n g X-rays of the s p i n e as  necessary  throughout  a curve.  Keim (1978) s t a t e s t h a t o n l y two  and  controlled  the y e a r s of growth to determine  p r o g r e s s i o n of  treatments, s p i n a l b r a c i n g  surgery e f f e c t i v e l y c o r r e c t s c o l i o s i s .  These treatments w i l l  be  c o n s i d e r e d i n terms of e f f i c a c y and a c c e p t a b i l i t y as the components of e f f e c t i v e n e s s u s i n g what i s d e s c r i b e d i n the There a r e d i f f i c u l t i e s e f f i c a c y of treatment  literature.  i n l o c a t i n g c o n c l u s i v e evidence of the  of s c o l i o s i s .  One  m i n a t i o n of d i f f e r e n c e s i n outcome due  problem l i e s i n the d e t e r -  to e a r l y d i a g n o s i s and  treatment  of  s c o l i o s i s wheir t h e r e i s l a c k of knowledge about the n a t u r a l .history  of  the d i s e a s e , t h a t i s , which curves w i l l p r o g r e s s .  v i o u s l y some curves can even spontaneously et  a l . 1978).  Other d i f f i c u l t i e s  p a n c i e s i n measuring c u r v e s . can be shown to v a r y up The proposed examining ative  improve (Brooks  occur because t h e r e may  Rogala  et a l . (1978) found  to 5° w i t h d i f f e r e n t  treatment  As mentioned p r e 1977; be  discre-  t h a t any  curve  examinations.  f o r s c o l i o s i s w i l l be c o n s i d e r e d by  evidence as to the e f f e c t i v e n e s s of n o n - o p e r a t i v e  approaches.  Rogala  and  oper-  30  Non-operative  approaches  E x e r c i s e s are mentioned as treatment by Keim (1978) so t h a t c o u l d s t r o n g l y condemn them as a s o l e cure f o r s c o l i o s i s .  He  he  rejects  the p r a c t i c e of d e t e c t i n g a p a t i e n t e a r l y and p r e s c r i b i n g an e x e r c i s e program and severe.  thus l o s i n g the p a t i e n t to f o l l o w - u p u n t i l the curve i s  In a study r e p o r t e d by Stone  et a l . (1979) i t was  concluded  t h a t e x e r c i s e had no e f f e c t on change i n c u r v a t u r e of 42 p a t i e n t s w i t h minimal  idiopathic scoliosis  ( d e f i n e d as l e s s than 2 0 ° ) .  James (1976) r e p o r t s on a 1941 t r e a t e d by e x e r c i s e .  The  study of s e v e r a l thousand  c o n c l u s i o n was  cases  t h a t e x e r c i s e s were demon-  s t r a b l y i n e f f e c t i v e i n c o n t r o l l i n g a curve's d e t e r i o r a t i o n or i n improving curves a l r e a d y p r e s e n t . 42 a d o l e s c e n t s w i t h minimal No  Brooks (1980) r e p o r t s on a study of  i d i o p a t h i c curves g i v e n an e x e r c i s e regime.  s i g n i f i c a n t improvement was  found i n comparing the study group w i t h  a c o n t r o l group d u r i n g the 9 to 15 month study p e r i o d . B r a c i n g to t r e a t s c o l i o t i c the Milwaukee b r a c e .  curves i s u s u a l l y accomplished  with  I t i s recommended i n g e n e r a l f o r p r o g r e s s i v e  f l e x i b l e c u r v a t u r e of 20° to 40° i n growing  children.  The main  purpose  of the b r a c e i s to p r e v e n t p r o g r e s s of the curve w i t h the secondary of improving  the curve (Moe  the b r a c e averages yearly.  e t a l . 1978).  three years.  X-rays may  The l e n g t h of treatment  aim with  be taken t h r e e or more times  Response to the b r a c e i s v a r i a b l e and u n p r e d i c t a b l e , t h e r e f o r e  m o n i t o r i n g the curve i s e s s e n t i a l .  I t must not be worn by p a t i e n t s  whose curves p r o g r e s s w h i l e they are wearing i t . S e v e r a l s t u d i e s have .been done which g i v e e n d - r e s u l t e v a l u a t i o n s a y e a r or so a f t e r completion of the b r a c e program.  One  such study by  Edmonson and M o r r i s (1977) c o n s i d e r e d a group of 52 p a t i e n t s f o l l o w e d f o r more than s i x months and an average of b r a c e wearing. accomplished  The  of 22 months a f t e r c e s s a t i o n  c o n c l u s i o n reached was  i n b r a c i n g was  not as g r e a t as f o r s u r g e r y however p r o -  g r e s s i o n of curves under 60° was  usually halted.  i n some curves d i d occur t h i s g r a d u a l l y was A study of l o n g term r e s u l t s was al.  t h a t the improvement  Although  improvement  l o s t a f t e r treatment  ceased.  c a r r i e d out by Mellencamp et  (1977) of 47 p a t i e n t s completing treatment of at l e a s t f i v e y e a r s  w i t h the Milwaukee b r a c e .  There was  no s t a t i s t i c a l l y s i g n i f i c a n t v a r -  i a t i o n when the r e s u l t s were a n a l y s e d a c c o r d i n g t o age, s i z e of curve or l o c a t i o n of curve. correction. range was  The  O n e - t h i r d of p a t i e n t s l o s t 5° of  o t h e r t w o - t h i r d s had  initial  their  curves which p r o g r e s s e d .  from a g a i n of 40° to a l o s s of 26°.  f i n d i n g s of t h i s study were t h a t t h e r e was  The most  The  important  extreme v a r i a b i l i t y  i n the  age a t which curves s t a b l i z e d or a t which c o r r e c t i o n o c c u r r e d and v a r i a t i o n i n the e n d - r e s u l t s . s t u d i e s were randomized Blount  The main d e f i c i t was  clinical  trials  that n e i t h e r of these  of b r a c i n g .  (1981) emphasizes the importance  of u s i n g the Milwaukee  b r a c e o n l y i n curves o c c u r r i n g i n immature g i r l s so that v e r t e b r a e be reshaped w i t h growth.  The b r a c e may  c o r r e c t curves i n those near  s k e l e t a l m a t u r i t y but the s p i n e w i l l not m a i n t a i n the c o r r e c t i o n w i l l r e t u r n to the o r i g i n a l curve. acceptable curve. choice.  The  and  crux i s whether t h i s i s an  I f i t i s n o t , then s u r g e r y should be the o r i g i n a l  In e v a l u a t i o n of e f f i c a c y of b r a c i n g i t would be important  know i f b r a c i n g were a p p l i e d o n l y to those curves meeting of immaturity  may  or i f the sample was  the  u n s e l e c t e d as to bone age.  to  criteria  32  A randomized done.  clinical  t r i a l of the Milwaukee b r a c e has not been  I t might be c o n s i d e r e d u n e t h i c a l a t t h i s p o i n t i n time  because  of the g e n e r a l b e l i e f by o r t h o p e d i c surgeons u s i n g the t e c h n i q u e t h a t it  i s b e n e f i c i a l but the o n l y evidence a v a i l a b l e as to i t s e f f i c a c y i s  from e n d - r e s u l t s of c h i l d r e n i n b r a c i n g programs and t h e s e r e s u l t s are equivocal. In s e a r c h i n g the l i t e r a t u r e f o r evidence of the a c c e p t a b i l i t y of b r a c i n g t h e r e were l i m i t e d r e p o r t s a v a i l a b l e . t h a t the Milwaukee b r a c e may its  suitability  Wickers  (1977) s t a t e s  be r e j e c t e d by some a d o l e s c e n t s d e s p i t e  f o r treatment of t h e i r c o n d i t i o n .  Concern about  d i f f e r e n t , b e i n g l e s s mobile and h a v i n g to wear camouflaging have been c i t e d as reasons f o r r e f u s a l to wear the b r a c e . Kettleson  clothing  Moe  and  (1970) r e p o r t 20 p e r c e n t of t h e i r p a t i e n t s r e f u s e d to wear  their braces.  O n e - t h i r d of b r a c e p a t i e n t s r e q u i r e d i n t e r v e n t i o n to  overcome p s y c h o l o g i c a l d i f f i c u l t i e s  i n a d j u s t i n g to b r a c e  (Heckman-Schatzinger  Gurr  et a l . 1977).  a two y e a r p e r i o d of 4 of 75 c h i l d r e n who  Operative  looking  treatment  (1977) r e p o r t s r e f u s a l s had b r a c e s  over  prescribed.  approaches  Surgery i s needed f o r those cases not manageable by b r a c i n g or f o r large i n f l e x i b l e curves.  There appears  to be g e n e r a l agreement  t h a t curves over 50° r e q u i r e s u r g e r y , curves from 40° to 50°  may  r e q u i r e o p e r a t i v e treatment and those under 30° can be d e a l t w i t h more conservatively. literature  These recommendations appear  (James 1976;  w i t h o r t h o p e d i c surgeons  Moe  et a l . 1978)  ( T r e d w e l l 1981).  q u i t e u n i f o r m l y i n the  and i n d i r e c t  communication  33  The s u r g i c a l approach to treatment Harrington Instrumentation with fusion. s u r g i c a l treatment that c o r r e c t i o n  for scoliosis i s usually  Moe  by  et a l . (1978) s t a t e t h a t  i s s a f e i n good hands, w h i l e James (1976) suggests  ( i . e . t r a c t i o n ) f o l l o w e d by f u s i o n of the s p i n e i s the  b a s i c treatment method f o r s c o l i o s i s except f o r s l i g h t curves managea b l e by b r a c i n g . Evidence Goldstein 80).  of the e f f e c t i v e n e s s of s u r g e r y has been r e p o r t e d by  (1969) but a p s e u d a r t h r o s i s r a t e of 5 p e r c e n t o c c u r r e d  In the 76 p a t i e n t s w i t h s o l i d  r e c t i o n averaged  7° or l e s s .  approach averaged  and n e u r o l o g i c a l damage. S o c i e t y quotes  f u s i o n p o s t - o p e r a t i v e l o s s of c o r -  Ponder (1975) w i t h an e a r l i e r m o b i l i z a t i o n  a l o s s of 5.3°  t h r o s i s r a t e of 5 p e r c e n t .  i n curve c o r r e c t i o n and a  Other  A study by  an i n c i d e n c e of 0.7  percent  (Ponder  1975).  pseudar-  complications occurring are the American S c o l i o s i s  The morpercent  Edgar (1980) r e p o r t e d a 15° average  d e t e r i o r a t i o n p o s t - o p e r a t i v e l y i n a d o l e s c e n t s between f u s i o n maturity.  D e t e r i o r a t i o n i n a d u l t l i f e averaged  Acceptance in  and  curve  and  2°.  of the recommendation f o r s u r g e r y was  the l i t e r a t u r e but one  infection  Research  p e r c e n t f o r the l a t t e r .  t a l i t y r a t e has been r e p o r t e d v a r i o u s l y as 6 p e r c e n t , 0.07 1.4  (4 of  not documented  can surmise some r e l u c t a n c e to have a c h i l d  undergo major s u r g e r y w i t h p o s t - o p e r a t i v e i n c a p a c i t y f o r s e v e r a l months when the c h i l d may  Acceptance  have been symptomless and appear normal to the p a r e n t s .  of i n i t i a l  referral  B e f o r e l e a v i n g the aspect of a c c e p t a b i l i t y of the t h e r e i s another  treatment,  l e v e l of a c c e p t a b i l i t y p r i o r t o e i t h e r b r a c i n g or  34  s u r g e r y and  t h a t i s the acceptance  of the i n i t i a l r e f e r r a l f o r m e d i c a l  assessment a f t e r s c r e e n i n g has determined  a possible scoliosis  Brooks et a l . (1975) found among a group of 374 observed  a f t e r a s c r e e n i n g program t h a t 25.9  curve.  patients being  percent refused f u r t h e r  e v a l u a t i o n or were l o s t to f o l l o w - u p . In an O n t a r i o study i n 1977, c h i l d r e n were r e f e r r e d f o r m e d i c a l f o l l o w - u p a f t e r s c r e e n i n g and was  no evidence of a completed  ( W i l l i a m s and T i c e 1980). referrals failed  r e f e r r a l i n 20 p e r c e n t of the  there  cases  I n a North Vancouver study o n l y 2 of  to comply w i t h r e f e r r a l  827  307  (North Shore H e a l t h Department  1981). To complete c o n s i d e r a t i o n of t h i s c r i t e r i o n mention should  be  made of the c o n c l u s i o n of the Task F o r c e on the P e r i o d i c H e a l t h Examination  (1980) t h a t e f f i c a c y of treatment was  because of the incompleteness  of f o l l o w - u p d a t a and  improvement c o u l d occur w i t h o u t methods of treatment  While  treatment.  to  determine  the f a c t t h a t  Evidence p r e s e n t e d  on  such as the Milwaukee b r a c e are not a c c e p t a b l e  because none are based study d e s i g n .  difficult  on c a s e - c o n t r o l or even q u a s i - e x p e r i m e n t a l  surgery prevents  the d e f o r m i t y from p r o g r e s s i n g  i t has an accompanying m o r t a l i t y and m o r b i d i t y .  In t h i s Task Force  r e p o r t the e f f e c t i v e n e s s of p r e v e n t i o n / t r e a t m e n t  i s g i v e n as "unknown".  3.  F a c i l i t i e s f o r d i a g n o s i s and  treatment  should be  available  Wingate (1977) and F r o s t (1978) d i s c u s s d i a g n o s t i c and ment f a c i l i t i e s which a r e n e c e s s a r y b e f o r e i n t r o d u c t i o n of  treat-  scoliosis  s c r e e n i n g programs. In  p l a n n i n g f o r the implementation  of s t a t e w i d e s c r e e n i n g i n  Hawaii, F r o s t (1978) c o n s i d e r e d ment and mence.  s u p p l i e s and The  community r e s o u r c e s  number of o r t h o p e d i c  s p e c i a l i z i n g i n s c o l i o s i s , and clinics  the a v a i l a b i l i t y of p e r s o n n e l ,  equip-  b e f o r e s c r e e n i n g would com-  specialists, particularly  of c l i n i c f a c i l i t i e s  to other areas) were a l l reviewed.  (including v i s i t i n g  No mention was  r a d i o l o g i c a l s e r v i c e s or o r t h o t i c ( b r a c i n g )  those  made of  resources.  Wingate (1977) s t r e s s e d the importance of c o n s i d e r a t i o n of a v a i l a b l e d i a g n o s t i c and  treatment f a c i l i t i e s when i n t r o d u c i n g s c o l -  i o s i s s c r e e n i n g i n an urban s e t t i n g . must be p o s s i b l e and  She mentions t h a t s p i n a l X-rays  r e f e r r a l c e n t r e s a l e r t e d to the p o s s i b l e i n f l u x .  Here a l s o no mention i s made of b r a c e s e r v i c e or o r t h o p e d i s t s but may  be  considered  p a r t of the c l i n i c  this  resources.  T a y l o r e t a l . (1978b) suggest t h a t a s c h o o l s c r e e n i n g program f o r s c o l i o s i s s h o u l d not commence w i t h o u t d i a g n o s t i c and  treatment s e r v i c e s .  They found t h a t i n A u s t r a l i a  were d e f i c i t s i n the number of o r t h o p e d i c s t a t e of development of o r t h o t i c s . s c r e e n i n g without  and  o n l y be  f o r appointments  inadequate b r a c e maintenance.  The  that w h i l e s c r e e n i n g programs c o u l d under the r i g h t an admirable a d d i t i o n to p u b l i c h e a l t h s e r v i c e s they  i n t r o d u c e d under the prime m e d i c a l  f o r the r i g h t reasons,  a t the r i g h t  the r e s o u r c e s  conshould  g u i d e l i n e s "the r i g h t  thing,  time" ( T a y l o r e t a l . 1978b, p.  In the l a r g e s c h o o l s c r e e n i n g programs begun i n M o n t r e a l 1974  i n the  They a l s o suggest i n s t i t u t i o n of  c h i l d r e n , long waits  n e c e s s i t a t i n g i n v o l v e d t r a v e l and  d i t i o n s be  surgeons a v a i l a b l e and  there  c o n s i d e r i n g a v a i l a b l e treatment c o u l d c r e a t e a dilemma  caused by anxious p a r e n t s  conclusion:  c o n s i d e r a t i o n of a v a i l a b l e  which were c o o r d i n a t e d  as i n t e g r a l p a r t s of  in the  3).  program i n c l u d e d the community h e a l t h department, s c h o o l nurses and h o s p i t a l medical  c e n t r e s e r v i c e s such as the m e d i c a l  i o l o g y , physiotherapy records  and o r t h o t i s t .  consultant,  rad-  Administrative services f o r  and d a t a c o l l e c t i o n and t h e bus company were other s e r v i c e s  i n c l u d e d i n the "team" which was managed by a program c o o r d i n a t o r (Gurr  1977). I t i s g e n e r a l l y agreed t h a t b e f o r e s c r e e n i n g begins  personnel  should be a v a i l a b l e t o c a r r y out s c r e e n i n g and t h a t d i a g n o s t i c and treatment f a c i l i t i e s screening  4.  should be capable  of a b s o r b i n g  r e f e r r a l s from the  program.  There should be a r e c o g n i z a b l e l a t e n t or e a r l y symptomatic In t h e e a r l y or p r e c l i n i c a l stages  p a i n or other  shoulder iliac  t h e r e i s no  symptoms, b u t c e r t a i n s i g n s do occur which may be i n d i -  c a t i v e of pathology. on forward  of s c o l i o s i s  stage  These e a r l y s i g n s i n c l u d e v i s i b l e f i x e d r o t a t i o n  bending ( t h e c l a s s i c r i b hump), s c a p u l a r prominence, unequal  l e v e l , u n e q u a l w a i s t a n g l e s , p e l v i c o b l i q u i t y as evidenced  by  c r e s t l e v e l and plumb bob misalignment (Keim 1978; Hoe et. a l .  1978). I t i s agreed t h a t t h e r e i s a s t a g e o f s c o l i o s i s when an e a r l y curve may be d e t e c t e d b u t i t i s d i f f i c u l t e a r l y curves curves  to determine which of these  a r e s i g n i f i c a n t , t h a t i s , which a r e minor  non-progressive  not r e q u i r i n g c o n t i n u i n g management and those which w i l l become  p r o g r e s s i v e severe w i l l be d i s c u s s e d history.  structural deformities.  This aspect  of s c o l i o s i s  i n more d e t a i l under c r i t e r i o n seven - t h e n a t u r a l  37  5.  There should be a s u i t a b l e t e s t or examination  D e s c r i p t i o n of the t e s t s The commonly r e c o g n i z e d s c r e e n i n g t e s t f o r s c o l i o s i s i s desc r i b e d i n the S c r e e n i n g Handbook of the S c o l i o s i s Research S o c i e t y , as a forward bending t e s t , w i t h the f e e t t o g e t h e r , c l o t h i n g removed to the h i p s , i n which  the examiner  ward bending p o s i t i o n s .  observes the s p i n e i n u p r i g h t and f o r -  There i s another l e s s common method of s c r e e n -  i n g u s i n g photogrammetry c a l l e d t h e Moire t e s t . t i o n e d i n f r o n t o f a s c r e e n of f i n e w i r e s .  The s u b j e c t i s p o s i -  A l i g h t i s projected  through  the s c r e e n and shadows from the w i r e s o u t l i n e the contours of the subj e c t ' s back. terns  A photograph  (Howell e t a l . 1978).  reviewed a f t e r  i s taken and s t u d i e d f o r asymmetrical p a t The s u i t a b i l i t y  of the M o i r e t e s t w i l l be  the s t a n d a r d t e s t .  The c r i t e r i a f o r a s c r e e n i n g t e s t have been d i s c u s s e d p r e v i o u s l y (Cochrane and H o l l a n d 1971, S a c k e t t 1975b) and s e l e c t e d ones a r e a p p l i e d to the s c o l i o s i s s c r e e n i n g t e s t as f o l l o w s :  Simplicity The t e s t i s easy t o understand and r i b humps of marked are obvious.  No expensive equipment i s r e q u i r e d  i n testing.  degree  Lonstein  (1977) suggests the t e s t can be done by s c h o o l nurses or p h y s i c a l  educa-  t i o n t e a c h e r s and a l a r g e group p r o c e s s e d r a p i d l y and e a s i l y "a 30 second investment f o r a l i f e t i m e of d i v i d e n d s " .  Validity Wingate (1977) as w e l l as H o w e l l and C r a i g as the key c r i t e r i o n f o r a t e s t .  Validity  (1980) g i v e v a l i d i t y  can be measured i n terms o f  the s e n s i t i v i t y , s p e c i f i c i t y ,  ( o r f a l s e p o s i t i v e and f a l s e  r a t e s ) as w e l l as by the p r e d i c t i v e v a l u e . suggest  negative  Howell and C r a i g (1980)  t h a t the p r e d i c t i v e v a l u e of a p o s i t i v e t e s t  b e s t i n d i c a t o r o f v a l i d i t y of a s c r e e n i n g t e s t .  (PVPT) i s the  In a study a s s e s s i n g  p h y s i c i a n s c r e e n e r s H o w e l l et a l . (1980b) found a PVPT range of 7 p e r cent to 30 p e r c e n t f o r curves equal or g r e a t e r than 15° and 31 p e r c e n t to 54 p e r c e n t f o r curves equal or g r e a t e r than 10°.  Comparing nurses  and p h y s i c i a n s i n v a l i d i t y of s c r e e n i n g d e c i s i o n s , the f o l l o w i n g i s reported:  f o r curves equal to or g r e a t e r than 10° - n u r s e s '  sensitiv-  i t y 71 p e r c e n t , s p e c i f i c i t y 36 p e r c e n t , p h y s i c i a n s ' s e n s i t i v i t y  81  p e r c e n t , s p e c i f icity-'22 p e r c e n t , w h i l e f o r curves equal to or g r e a t e r than 15° - n u r s e s ' s e n s i t i v i t y 76 p e r c e n t , s p e c i f i c i t y 35 p e r c e n t , physicians' s e n s i t i v i t y  81 p e r c e n t , s p e c i f i c i t y  V e r r i e r et a l . (1979) a s s e s s e d test i n a t r i a l  the v a l i d i t y  i n E t o b i c o k e , O n t a r i o and found  c h i l d r e n seeded w i t h 16 confirmed  21 p e r c e n t . of the s c r e e n i n g  t h a t i n a sample of 60  s c o l i o t i c s who were screened by pub-  l i c h e a l t h n u r s e s , p h y s i o t h e r a p i s t s , a p h y s i c i a n and by o n l y one c h i l d was  found  f r e e of s c o l i o s i s by a l l s c r e e n e r s and o n l y  two were found p o s i t i v e by a l l examiners. i n t e r - r a t e r agreement.  photographers,  In t h i s study  O v e r a l l there was  to e l i m i n a t e the p o s s i b i l i t y of  poor t r a i n i n g of the r a t e r s i n use of the s c r e e n i n g t e s t , t r a i n i n g was  60 p e r c e n t  additional  g i v e n to a l l r a t e r s w i t h no s i g n i f i c a n t improvement i n a  second s c r e e n i n g e x p e r i e n c e . In c o m p l e t i o n  of a f o u r f o l d  t a b l e V e r r i e r found  p e r c e n t , s p e c i f i c i t y 40 p e r c e n t , and PVPT 35 p e r c e n t . as determined  sensitivity  77  Overall v a l i d i t y  by the number of c h i l d r e n a c c u r a t e l y c l a s s i f i e d was  51  percent.  These r e s e a r c h e r s  t h a t the r e l i a b i l i t y  and  concluded on the b a s i s of these r e s u l t s  validity  of the t e s t f o r s c o l i o s i s was  ques-  tionable.  Repeatability T h i s can be a s s e s s e d by measuring i n t e r r a t e r , intermethod i n t r a r a t e r agreements.  V e r r i e r et a l . (1979) r e p o r t on a l l t h r e e  t h e i r study i n O n t a r i o .  I t was  reported  s e l v e s an average of 61 p e r c e n t r a t e r agreement was  69 p e r c e n t  in  t h a t r a t e r s agreed w i t h them-  of the time. (standard  O v e r a l l average of  d e v i a t i o n of 11  Intermethod agreement ( u s i n g Moire photograph) was A l l r a t e r s (physiotherapists, nurses, physicians) likely  and  inter  percent).  59 p e r c e n t were found  overall. equally  to make e r r o r s .  Cost D i r e c t c o s t of s c r e e n i n g acceptable  because of the use  itself  i s g e n e r a l l y agreed to  of v o l u n t e e r s  and  available  however the i n d i r e c t c o s t s are not always i n c l u d e d , c i a n s and  specialists.  c o s t s are s i g n i f i c a n t . of s c r e e n i n g  as  I n view of the h i g h Moe  $1684 per  e a r l y d e t e c t i o n , assuming one would be  $5500 (Moe  readers that besides  et a l . 1978).  i n 400  c o s t of s c r e e n i n g  c o s t s - f o r time l o s t , a n x i e t y In summary the standard  and  He  required  Williams  physi  f a l s e p o s i t i v e r a t e these  s t u d e n t s screened. child  personnel;  i . e . X-rays,  r e p o r t s on c o s t a c c o u n t i n g  400  be  and  and  gives  cost  suggests w i t h o u t surgery  the  cost  T i c e (1980) remind  and m e d i c a l f o l l o w - u p  indirect  f e a r - must be accounted f o r .  screening  t e s t appears to meet the c r i  t e r i a of a s u i t a b l e t e s t on the grounds of s i m p l i c i t y and  d i r e c t costs  40 but evidence on v a l i d i t y and r e p e a t a b i l i t y raises concerns as do the i n d i r e c t costs generated by screening. Moire test The c r i t e r i a of s i m p l i c i t y , v a l i d i t y , r e p e a t a b i l i t y and cost w i l l be considered b r i e f l y i n r e l a t i o n to the Moire test as reported in the l i t e r a t u r e . There have been several studies u t i l i z i n g photogrammetry along with c l i n i c a l screening (Howell et a l . 1978; Howell and Craig 1980; Howell et al. 1980).  This technique involves use of heavy equipment  which requires transportation. been noted (Howell et a l . 1980).  D i f f i c u l t i e s positioning subjects have Seventy-one percent of curves of 10°  or more went undetected (Howell et a l . 1978).  Verrier et a l . (1979)  in a study to compare Moire topography and physical examination found an unacceptably low rate of r e l i a b i l i t y and v a l i d i t y with an unacceptably high l e v e l of f a l s e positives and negatives.  Because of those  unacceptable findings use of the Moire test i s s t i l l i n the experimental state.  The reduction of expensive time required to screen large numbers  of  children was anticipated to be an advantage of this method (Howell  et  a l . 1980).  This p o s s i b i l i t y keeps interest i n i t s development high.  It appears the Moire test f a i l s to meet the c r i t e r i a of a simple, v a l i d , r e l i a b l e test and the question on cost i s s t i l l unanswered. 6.  The test should be acceptable to the population Stangler et a l . (1980) proposes that a l l who w i l l be affected  by a screening test should find i t acceptable.  This includes families,  children, the professionals who receive the r e f e r r a l s and the whole community.  41  In some areas where a s i g n e d p a r e n t a l consent was  required  b e f o r e s c r e e n i n g 85 p e r c e n t to 90 p e r c e n t were r e t u r n e d ( W i l l i a m s and T i c e 1980).  These same i n v e s t i g a t o r s suggest  added to the consent problems was  form to determine  i f p r e v i o u s h i s t o r y of back  a r e a s o n f o r r e f u s a l to consent  areas a consent  t h a t q u e s t i o n s c o u l d be  to s c r e e n i n g .  form a l o n g w i t h an e x p l a n a t o r y l e t t e r was form was  I n other used  e t a l . 1978).  The  to be r e t u r n e d o n l y i f t h e r e was  to s c r e e n i n g .  They r e p o r t t h i s a h i g h l y a c c e p t a b l e method.  Vancouver H e a l t h Department a l s o uses the d i s s e n t method of (1981). 875  refusals  objection The  (2 p e r c e n t )  (Frost  (3 p e r c e n t ) and  18  involving student  1978).  Howell and C r a i g (1980) recommend from where a l l grade seven g i r l s are screened,  t h e i r Edmonton  experience  t h a t because a d o l e s c e n t  a r e e a s i l y p e r t u r b e d by the program i t should be de-emphasized. accomplish  t h i s by having  was  semi-nudity  caused  They  Wingate (1977) found  that  undres-  some embarrassment but i n g e n e r a l the  test  acceptable. A c c e p t a b i l i t y of the Moire  t e s t was  o n l y 70 p e r c e n t to 80  cent i n one Ottawa study, because p a r e n t s misunderstood assumed r a d i a t i o n was c e r n expressed was and  girls  the r e g u l a r s c h o o l nurse do s c r e e n i n g as p a r t  of grade seven p e r i o d i c examinations. s i n g and  North  consent  D u r i n g a s c o l i o s i s s c r e e n i n g p i l o t p r o j e c t i n Hawaii  c h i l d r e n t h e r e were 24 p a r e n t r e f u s a l s  (Howell  i n v o l v e d (Columbian  per-  the t e s t and  A p r i l 7, 1979).  Another  . con-  the l a c k of p r i v a c y because the b u t t o c k s were exposed  the embarrassment caused by the presence  of a young male t e c h n i c i a n .  P h y s i c i a n , acceptance Another recommendation from the study  of W i l l i a m s  (1980) was t h a t p h y s i c i a n s i n Scarborough be surveyed  and T i c e  t o determine  t h e i r views on the s c r e e n i n g program and. c r i t e r i a f o r d i a g n o s i s and management.  The survey  c o u l d i d e n t i f y p h y s i c i a n acceptance of t h e  program. There appears to be arrange of a c c e p t a b i l i t y of s c o l i o s i s screening reported  i n the l i t e r a t u r e of from 70 percent  t o 95 p e r c e n t .  7. The n a t u r a l h i s t o r y of t h i s c o n d i t i o n i n c l u d i n g t h e development from l a t e n t t o d e c l a r e d d i s e a s e should be adequately understood The with  n a t u r a l h i s t o r y of a d i s e a s e i s l e a r n e d by s t u d y i n g  the c o n d i t i o n who have not had treatment.  cent i d i o p a t h i c s c o l i o s i s  The course  i s u n c l e a r i n some r e s p e c t s .  those  of a d o l e s -  Moe (1980,  p. 90) comments t h a t We a r e s t i l l f a r from t h e u l t i m a t e g o a l of knowing i t s ( s c o l i o s i s ) e t i o l o g y and d e t e r m i n i n g which of the s m a l l curves a r e going to p r o g r e s s to severe curves . . . Taylor  (1978a) suggests t h a t data  t o r y of minor c u r v a t u r e s .  Blount  i s u r g e n t l y needed on the n a t u r a l h i s (1981) f e e l s the l a c k of a c c u r a t e  i n f o r m a t i o n about p a t i e n t s under o b s e r v a t i o n b e f o r e 1960 makes t h e study  of the n a t u r a l h i s t o r y of s c o l i o s i s over a l o n g p e r i o d  difficult.  He sees t h a t t h i s s i t u a t i o n w i l l be improved i n the f u t u r e w i t h the a v a i l a b i l i t y of present  r e c o r d s which document s k e l e t a l age as w e l l as  o t h e r r e l e v a n t i n f o r m a t i o n needed t o d e s c r i b e t h e n a t u r a l h i s t o r y of scoliosis.  43  S t u d i e s of u n t r e a t e d c u r v e s d u r i n g growth There a r e t h r e e p o s s i b l e outcomes f o r a c u r v e : r e s o l u t i o n , no change and p r o g r e s s i o n . more curves p r o g r e s s i n g i r l s  spontaneous  As has been d i s c u s s e d p r e v i o u s l y  than boys, and those most a t r i s k f o r  p r o g r e s s i o n a r e immature females w i t h curves over 10° (Rogala e t a l . 1978). P o n s e t i and Friedman (1950) i n a review o f 394 p a t i e n t s , 335 of whom were f o l l o w e d t o m a t u r i t y , found  t h a t the most s e v e r e p r o g r e s s i o n s  were r e l a t e d t o e a r l y onset o f the c u r v e . most, w i t h the average The average  T h o r a c i c curves p r o g r e s s e d  t h o r a c i c curve a t m a t u r i t y 81° ( i n 71 p a t i e n t s ) .  curve i n the r e m a i n i n g cases was between 35° and 52°.  S t u d i e s of u n t r e a t e d curves a f t e r m a t u r i t y I n a f u r t h e r study o f 215 of these same p a t i e n t s ( C o l l i s and P o n s e t i 1969) most were found to have l e d n o r m a l l y p r o d u c t i v e l i v e s . While back p a i n was r e p o r t e d f r e q u e n t l y i t was minimal  and n o n - l i m i t i n g .  V i t a l c a p a c i t i e s were d i m i n i s h e d i n 45 p e r c e n t but o n l y 2 p e r c e n t had more than s l i g h t dyspnea on e x e r t i o n .  The death r a t e was s i m i l a r t o  the g e n e r a l p o p u l a t i o n . N i l s o n n e and Lundgren (1968) s t u d i e d the long-term p r o g n o s i s of 113 p a t i e n t s w i t h i d i o p a t h i c s c o l i o s i s up t o 50 y e a r s a f t e r d i a g n o s i s a t the average lost  age o f 15.9 y e a r s .  t o c o n t a c t , of the remainder  age of death was 46.6 y e a r s .  original  Only 11 of the 113 were  56 were a l i v e and 46 had d i e d .  Mean  The m o r t a l i t y r a t e was c a l c u l a t e d t o be  t w i c e as h i g h as f o r the g e n e r a l p o p u l a t i o n and c a r d i a c or pulmonary d i s e a s e accounted  f o r 60 p e r c e n t of deaths.  F o r t y - s e v e n p e r c e n t of the  44  l i v i n g p a t i e n t s were d i s a b l e d , 76 p e r c e n t of the females were  unmarried,  90 p e r c e n t r e p o r t e d back symptoms. Nachemson (1968) d i d a f o l l o w - u p study of 117 53 y e a r s a f t e r i n i t i a l d i a g n o s i s a t a mean age of 14. was  twice t h a t expected.  s c o l i o t i c c a r d i o p a t h y was  In 16 of 20 p a t i e n t s who listed  as cause of death.  the p a t i e n t s r e c e i v e d a d i s a b i l i t y p e n s i o n . i n 37 of 97  p a t i e n t s 48 to Mortality  rate  had d i e d , kyphoT h i r t y p e r c e n t of  R e c u r r i n g back p a i n o c c u r r e d  individuals.  I t i s agreed  t h a t curves over 60° o f t e n p r o g r e s s i n adulthood.  P o n s e t i e t a l . (1976) found i n c r e a s e d 15° or more and  t h a t i n 26 p e r c e n t of p a t i e n t s curves  i n 8 p e r c e n t of p a t i e n t s 25° or more.  Some  curves show l i f e l o n g i n c r e a s e . R e p o r t i n g of spontaneous improvement of curves shows wide v a r iation.  Brooks et a l . (1975) found 22 p e r c e n t of curves i n h i s study  p o p u l a t i o n of 3492 improved improved.  w h i l e Rogala r e p o r t e d 3 p e r c e n t  (19/603)  Improvement i s d e f i n e d as v i r t u a l d i s a p p e a r a n c e of the  on the roentgenogram from i n i t i a l  (Rogala e t a l . 1978)  to f i n a l v i s i t  (Rogala e t a l . 1978)  i t was  or a decrease of 5° or more  (Brooks e t a l . 1975). found  In Rogala's  curves and  10.3  study  t h a t 20 p e r c e n t of the curves i n  immature g i r l s of a magnitude of 20° to 30° d i d n o t p r o g r e s s . curves t h e r e was  p r o g r e s s i o n i n 2.1  In l e s s e r  p e r c e n t of c h i l d r e n w i t h 6° to 10°  p e r c e n t of c h i l d r e n w i t h curves g r e a t e r than 10°.  g r e s s i o n f o r the purpose  curve  Pro-  of t h a t study meant i n c r e a s i n g 5° or more t o  a f i n a l curve of 20° or more. The c o n c l u s i o n one can reach i s t h a t t h e r e remains  a l a c k of  i n f o r m a t i o n from p r o s p e c t i v e s t u d i e s on the n a t u r a l h i s t o r y of  scoliosis  and r e t r o s p e c t i v e s t u d i e s have a b i a s to g i v e i n f o r m a t i o n on those curves i n the t r e a t a b l e  8.  range.  There s h o u l d be an agreed upon p o l i c y on whom t o t r e a t as p a t i e n t s For  purpose of examining  this criterion,  treatment w i l l be  s i d e r e d as a c t i v e m e d i c a l f o l l o w - u p which i n c l u d e s o b s e r v a t i o n . i s some v a r i a t i o n i n the s t a n d a r d s f o r management of c h i l d r e n  con-  There  identi-  f i e d w i t h s p i n a l c u r v a t u r e p a r t i c u l a r l y i n the range o f s m a l l e r c u r v e s . Howell et a l . (1980b) r e p o r t s the c r i t e r i a agreed upon i n Edmonton s c r e e n i n g programs.  They f o c u s on curves of a t l e a s t  a v o i d unnecessary  The s c h o o l nurse rechecks  referrals.  curves every s i x months.  15° to  suspicious  There i s a c t i v e f o l l o w - u p of g i r l s w i t h curves  g r e a t e r than 15° to be s u r e they are b e i n g seen.  The g u i d e l i n e s e s t a b -  l i s h e d by an a d v i s o r y p a n e l to t h e i r programs were as f o l l o w s : I n t e r p r e t a t i o n of r a d i o g r a p h i c f i n d i n g s i n s c o l i o s i s While the p r o g n o s i s v a r i e s a c c o r d i n g to age and s t a t e of maturi t y i t may g e n e r a l l y be s a i d t h a t 1) curves of l e s s than 5° a r e w i t h i n normal v a r i a t i o n 2) curves of 5 - 9 ° a r e i n s i g n i f i c a n t 3) curves of 10°-19° r e q u i r e o b s e r v a t i o n w i t h c l i n i c a l r e - e x a m i n a t i o n every 3 months and r e X-ray a f t e r 6 months. I f no change i s seen, o b s e r v a t i o n i n t e r v a l can be extended t o c l i n i c a l examination y e a r l y f o r 2 y e a r s , w i t h r e X-ray i f change i s s u s p e c t e d . 4) curves of 20° or over s h o u l d be r e f e r r e d and may r e q u i r e treatment. (Howell et a l . 1980, p. 2) c  If  treatment i n c l u d e s o b s e r v a t i o n as some o r t h o p e d i s t s suggest,  " o b s e r v a t i o n i s a c t i v e treatment" ( T i b b i t s 1980), and Research  Society c a t e g o r i z e s i t as^the f i r s t  the S c o l i o s i s  l e v e l of treatment,  then  u s u a l l y persons w i t h curves over 10° a r e those c o n s i d e r e d by most e x p e r t s i n the l i t e r a t u r e t o r e q u i r e treatment.  Otherwise Rogala e t a l . (1978)  would suggest p r o g r e s s i o n of a curve by 5° or more to over 20° p l a c e s  46  the person in the treatment category.  The immature female with a curve  11° or more is most at risk and should be observed closely. Taylor (1978a) suggests there is no sound basis for management of curves under 25°, found by screening programs. He warns of the potential hazards of over exposure to radiation which could occur i f X-rays were taken at frequent intervals over an extended period of time to observe small curves.  Earlier Brooks et al. (1975) recommended follow-up of 5°  curves but in a more recent discussion (1980) suggested that 11° and greater curves should be followed. Kane (1977a) says any immature individual with a curve of 20° deserves treatment and any immature individual with a curve over 10° is "at risk" and should be followed. These two groups constitute the scoliosis population, in his opinion. Blount (1981) suggests that there has been failure to recognize the skeletal age in considering whether to brace patients with moderate scoliosis.  The magnitude of the curve is too often the sole criterion.  A progressive curve should be treated at an early age.  Bracing w i l l  not be effective for an unacceptable curve in an almost mature individual.  Although the curve may improve i t w i l l return to i t s prebrace  level later because there has been no vertebral reshaping with growth. In Sweden where school children are regularly examined for scoliosis few patients in whom brace treatment is begun early require surgery later (11 of 477 patients where curve was less than 40°) (Torell et al. 1981). There is some lack of agreement on who to treat as a scoliosis patient.  A l l would agree that immature individuals are the ones "at  47  r i s k " but whether the l e v e l f o r concern  i s a t 11°, 15° or 25° v a r i e s  w i t h the p u b l i c a t i o n .  9. There should be economic b a l a n c e of t h e c o s t of c a s e - f i n d i n g i n r e l a t i o n t o t o t a l e x p e n d i t u r e on m e d i c a l c a r e There a r e l i m i t s to h e a l t h c a r e . another.  t o the r e s o u r c e s which any s o c i e t y can devote  Funds spent i n one a r e a mean b e n e f i t s foregone i n  W i l s o n and Jungner (1968) suggest  i t would be h e l p f u l t o  compare the economics o f m e d i c a l c a r e through of t h e same e x p e n d i t u r e on c o n v e n t i o n a l c a r e . a p r o s p e c t i v e study i s needed t o determine  s c r e e n i n g w i t h the r e s u l t s To do t h i s  they  suggest  i f m o r b i d i t y has been reduced  and working l i f e improved i n a screened p o p u l a t i o n compared t o an unscreened  sample.  Cochrane and H o l l a n d (1971) have suggested  t h a t the d e c i s i o n  of whether the c o s t o f s c r e e n i n g i s r e a s o n a b l e can be made by c o s t i n g s c r e e n i n g programs c a r e f u l l y and then a s k i n g a group o f l a y and m e d i c a l people whether such c o s t i s a c c e p t a b l e . There i s a d e a r t h of i n f o r m a t i o n about the c o s t of s c o l i o s i s s c r e e n i n g i n r e l a t i o n to t o t a l c o s t s and no e x p e r i m e n t a l available.  evidence  Moe e t a l . (1978) c i t e s a study of Drummond i n M o n t r e a l i n  which " c o s t a c c o u n t i n g " was done. $1684 per 400 s t u d e n t s .  Cost of s c r e e n i n g was c a l c u l a t e d a t  The assumption  one would r e q u i r e s u r g i c a l treatment  was made t h a t of 400 c h i l d r e n  ( i f s c r e e n i n g had n o t occurred)  so t h a t w i t h o u t s c r e e n i n g the c o s t would be $5500.  D e t a i l s are not  a v a i l a b l e , b u t one would q u e s t i o n what was i n c l u d e d i n the c a l c u l a t e d c o s t s of s c r e e n i n g and whether a l l r e f e r r a l and f o l l o w - u p s e r v i c e s i n c l u d i n g X-ray,  p h y s i o t h e r a p y , o r t h o p t i c s and p h y s i c i a n v i s i t s f o r both  t r u e and  f a l s e p o s i t i v e are c a l c u l a t e d .  i s found under c r i t e r i o n  and  costs  11.  10. C a s e - f i n d i n g should be a continuous project Wilson  F u r t h e r d i s c u s s i o n of  process  and  not a "one-time"  Jungner (1968) suggest the s i n g l e - o c c a s i o n examina-  t i o n i s u s u a l l y of l i m i t e d v a l u e , p a r t i c u l a r l y  i n terms of "weeks" or  " f a i r s " because o n l y a s m a l l p r o p o r t i o n of the p o p u l a t i o n i s reached and  o n l y those who  have the c o n d i t i o n a t t h a t p a r t i c u l a r  time.  They  suggest t h a t c o n t i n u i n g examinations of the p o p u l a t i o n a t r i s k have great  advantages. I n the case of a d o l e s c e n t  likely  idiopathic scoliosis  to show e a r l y s i g n s between the ages of 10 and  the r e p o r t e d  options  f o r s c r e e n i n g have been one p e r i o d and  i n some cases  ing  adequate.  The  suggests t h a t a l t h o u g h i s not adequate and tenth  a l l screening  and  so  a one-time  screen-  S c o l i o s i s Research S o c i e t y  i s u s e f u l a "onee-and-done e f f o r t "  they recommend annual s c r e e n i n g i n the f i f t h  through  grades. Rogala et a l . (1978) i n a p r o s p e c t i v e study  s c r e e n i n g of both grade s i x students I t was  15 y e a r s  or more examinations  during that e a r l y adolescent t e s t has been c o n s i d e r e d  the d i s e a s e i s  concluded  successful. s c r e e n i n g was  and  those  i n Montreal  i n grades seven and  t h a t s c r e e n i n g between ages 12 to 14 y e a r s was  In Scarborough d i s t r i c t , done i n grade s i x and  seven g i r l s were screened  Ontario  described  ( W i l l i a m s and  grade e i g h t .  Tice  eight.  most 1980)  In Edmonton grade ••:  i n the e v a l u a t i v e program t a k i n g p l a c e  L o n s t e i n et a l . (1976) suggests y e a r l y s c r e e n i n g d u r i n g the " a t  there. risk"  y e a r s which he d e f i n e s as ages 10 to 13 or grades f i v e through e i g h t .  49  In Sweden s c r e e n i n g i s performed by as p a r t of r o u t i n e m e d i c a l ( T o r e l l e t a l . 1981). had  school doctors  and  nurses  s c r e e n i n g u s u a l l y at ages 7, 11 and  14  Wingate (1977) i n her p l a n f o r an urban program  the o b j e c t i v e of s c r e e n i n g c h i l d r e n a n n u a l l y between ages 8 and  Frost's  (1978) p l a n f o r a s t a t e w i d e  program i n Hawaii d e s c r i b e s  i d e a l t a r g e t group f o r s c r e e n i n g as i n c l u d i n g c h i l d r e n age but due  to r e a l i t i e s of l i m i t e d p e r s o n n e l  grade seven - was  considered  and  time, one  10  age  16.  the  to  15  group -  an adequate t a r g e t group.  Most s c o l i o s i s s c r e e n i n g programs d e s c r i b e d  i n the  literature  have been on-going programs however they u s u a l l y aim at s c r e e n i n g once only - i n e a r l y  adolescence.  11. C o s t - b e n e f i t and c o s t - e f f e c t i v e n e s s c h a r a c t e r i s t i c s of mass s c r e e n i n g and long-term therapy must be known. A mechanism f o r weighing c o s t s a g a i n s t b e n e f i t s should be a component of I n i t i a l screening a c t i v i t i e s . The long-term b e n e f i t s must outweigh the c o s t s i n c l u d i n g t h e r a p e u t i c c o s t s and d e t r i m e n t s due to l a b e l l i n g , The  criteria relating  to e s t i m a t i o n of b e n e f i t s a r e  considered  together. The  l a c k of s t u d i e s measuring c o s t s and b e n e f i t s of  for scoliosis  i s noted by V e r r i e r e t a l . (1979), although  that there i s a general b e l i e f her  contention  a r e those due  to secondary p r e v e n t i o n ,  from s c o l i o s i s  extensive care.  screening, follow-up,  d i a g n o s i s , o b s e r v a t i o n and  the c o r r e c t l y and  emotional  incorrectly labelled  It is  screening of e a r l y  Cost i n c l u d e s a l l c o s t s of treatment of  problem of i d e n t i f y i n g and measuring  i n t a n g i b l e s such as s o c i a l and  comments  t h a t i s , the p r e v e n t i o n  death, d i s a b i l i t y and  The  she  t h a t b e n e f i t s outweigh the c o s t s .  t h a t the b e n e f i t s which accrue  r e f e r r e d f o r care.  screening  those the  c o s t s and b e n e f i t s both f o r  i s also  recognized.  The Williams  i s s u e of i n d i v i d u a l v e r s u s  and  T i c e (1980).  Some might argue one  f u s i o n j u s t i f i e s a program, w h i l e c o s t s from s c r e e n i n g and  time, may  difficulty  be  i n p u b l i c h e a l t h occurs  No mechanism f o r a s s e s s i n g as a f e a t u r e of the s c r e e n i n g  because w h i l e  are h e l p e d ,  the  overall  T i c e 1980). c o s t s and b e n e f i t s had  been d e s i g n e d  program reviewed by Wingate (1977) , nor  of c o s t s , b e n e f i t s or e f f e c t i v e n e s s of s c r e e n i n g  grams a v a i l a b l e a t the time of her paper.  She  pro-  suggests t h a t i n the  o r g a n i z a t i o n of a model s c r e e n i n g program f o r an urban p o p u l a t i o n the c o s t s be measured.  I t i s her p r o p o s a l  teachers,  s c h o o l nurses,  c o s t s of t r a i n i n g of p e r s o n n e l  and  cases.  Other c o s t s she  c o s t of the time of  t h e r a p i s t s and  physicians;  c o s t s of r e f e r r a l to p h y s i c i a n s ,  p e d i a t r i c i a n s , o r t h o p e d i s t s , p h y s i o t h e r a p i s t s and g r e a t e s t c o s t s w i l l be  that  t h a t they i n c l u d e s a l a r y or  a p o r t i o n t h e r e o f , of the h e a l t h c a r e c o o r d i n a t o r , p h y s i c a l education  The  because of l a c k of a v a i l a b l e i n f o r m a t i o n  about program r e s u l t s ( W i l l i a m s and  were e s t i m a t e s  direct  the i n d i r e c t c o s t s f o r worry  aware of i n d i v i d u a l s who  c o s t s are not a p p r e c i a t e d  the  i n terms of the a c t u a l b e n e f i t s gained.  f o r the a d m i n i s t r a t o r be  by  c h i l d saved from s p i n a l  from a s o c i e t a l v i e w p o i n t  and m e d i c a l c a r e and  excessive  the h e a l t h u n i t may  public benefit i s discussed  f o r h o s p i t a l i z a t i o n and  orthotists.  surgery  The  f o r severe  i n c l u d e s are f o r l e t t e r s , postage and  data  collection. On  the o t h e r hand, a c c o r d i n g  i n g l y hard to measure i n d o l l a r s . mentioned as w e l l as  to Wingate, b e n e f i t w i l l be  Q u a l i t y of l i f e c o n s i d e r a t i o n s  exceedare  the avoidance of p h y s i c a l i n c a p a c i t y w i t h r e l a t e d  consequences to employment.  Wingate's c o n t e n t i o n  i s that  estimated  51  c o s t s of s u r g e r y s h o u l d be deducted  from program c o s t s on the  t h a t most p a t i e n t s would not have needed t h i s extreme form o f with early detection.  assumption treatment  The r a t i o n a l e i s t h a t e a r l y d e t e c t i o n w i t h b r a c -  i n g as n e c e s s a r y p r e v e n t s c u r v e s r e q u i r i n g s u r g e r y . t h a t r e g a r d l e s s o f whether b e n e f i t exceed  c o s t s , s o c i e t y must  the worth of improving the q u a l i t y of l i f e zens and d e c i d e on a h u m a n i t a r i a n b a s i s .  Her c o n c l u s i o n i s determine  f o r a s m a l l number of  citi-  The a s p e c t of f i n i t e r e s o u r c e s  and c h o i c e of the b e s t a l t e r n a t i v e s f o r those l i m i t e d d o l l a r s i s not discussed.  No mention  i s made of the '"opportunity c o s t " when r e s o u r c e s  are deployed i n s c r e e n i n g . The o p i n i o n t h a t s o c i e t y cannot a f f o r d p e r f e c t treatment f o r a l l p a t i e n t s and a l l c o n d i t i o n s i s p r e s e n t e d i n a d i s c u s s i o n o f the economics of the treatment of s c o l i o s i s  (Dahlberg, Nachemson 1977).  t a n t to n o t e t h i s study i s based on 1971  I t i s impor-  p r i c e s and Swedish m e d i c a l  p r a c t i c e , but i t i s i n t e r e s t i n g i n terms of b e i n g the o n l y a v a i l a b l e paper on the t o p i c .  These authors concluded t h a t the p r e s e n t day  treat-  ment of young p a t i e n t s w i t h t h o r a c i c curves showed an extremely h i g h b e n e f i t / c o s t and e f f e c t i v e n e s s r a t i o .  They a l s o concluded t h a t a d e f i -  n i t e economic b e n e f i t can be d e r i v e d from e a r l y b r a c e treatment i n younger p a t i e n t s compared to s u r g e r y a t a l a t e r d a t e . conclude t h a t e a r l y r e c o g n i t i o n i s h i g h l y a d v i s a b l e .  T h i s l e d them to T h e i r study i s  based on data from the Swedish d i s a b i l i t y p e n s i o n fund c o r r e l a t e d w i t h the degree o f c u r v a t u r e f o r i n d i v i d u a l s r e c e i v i n g a p e n s i o n . t h e i r premises  One  of  i s t h a t a f t e r treatment w i t h a brace curves do not p r o -  g r e s s - an i n a c c u r a t e assumption  i n l i g h t o f the s t u d i e s o f Edmonson  and M o r r i s (1977) and Mellencamp e t a l . (1977) who of curves a f t e r treatment  ceased.  documented p r o g r e s s  52  Aa mentioned i n d i s c u s s i o n of c r i t e r i o n n i n e c o n c e r n i n g Drummond and Rogala (Dwyer e t a l . 1978) i n s u r g i c a l costs a f t e r deduction  estimate  a s a v i n g of $600,000  of s c r e e n i n g c o s t s i n t h e i r  T a y l o r e t a l . (1978b) c r i t i c i z e s t h i s c o n c l u s i o n .  study.  They quote  conclusion that c o s t / b e n e f i t a n a l y s i s i s only u s e f u l i n very circumstances. deformity, critical  Because o f the long-term f o l l o w - u p  Shapiro's special  required i n s p i n a l  t h e i r c o n c l u s i o n i s t h a t t h e r e i s not a sound b a s i s f o r a  study  such as t h a t of Rogala e t a l . (1978).  (1968) have suggested t h a t without b e n e f i t , i t may  a balance  not be p o s s i b l e to decide  McKeown and  Knox  sheet r e l a t i n g c o s t to  about a s c r e e n i n g program i n  terms of a l t e r n a t i v e methods of d i a g n o s i s and On  costs,  treatment.  the b a s i s of a review of the p u b l i s h e d evidence  the Task  F o r c e f o r the Conference o f Deputy M i n i s t e r s o f H e a l t h on P e r i o d i c H e a l t h Examination r e p o r t e d  (1980) t h a t s c o l i o s i s s c r e e n i n g  f u l v a l u e i n terms of c o s t b e n e f i t . outcome of c h i l d r e n who i s considered  The  l a c k of i n f o r m a t i o n about  were t r e a t e d a f t e r d e t e c t i o n d u r i n g  a serious d e f i c i t .  s c r e e n i n g be done o n l y w i t h i n the c o n t e x t  the  screening  Because of l a c k of evidence  b e n e f i t s of a p a r t i c u l a r form of therapy  as to  the  the committee recommended that of an e v a l u a t i v e study.  extremely low y i e l d from s c r e e n i n g programs was recommendation.  i s of doubt-  The  another f a c t o r i n t h e i r  Because the Task Force Report r e p r e s e n t s a review of  p u b l i s h e d r e p o r t s on s c o l i o s i s and  i s of r e c e n t date t h e i r  conclusion  must be s e r i o u s l y weighed.  12. I d e a l l y an e s t i m a t e of the s o c i a l , b e n e f i t of p r e v e n t i n g , a r r e s t i n g or c u r i n g the c o n d i t i o n . s h o u l d be known and i f community b e n e f i t s - a r e claimed to r e s u l t from s c r e e n i n g t h i s b e n e f i t must w i t h s t a n d s c i e n t i f i c s c r u t i n y G e n e r a l l y the s o c i a l b e n e f i t claimed  i s t h a t documented i n s t u d i e s  53  such as, those o f Nachemson Drummond e t a l . (1976).  (1968), N i l s o n n e and Lundgren (1968), and  These s t u d i e s i n d i c a t e the r e s t r i c t e d  a b i l i t y of p a t i e n t s with untreated s c o l i o s i s . p a t i e n t s were q u e s t i o n e d .  working  In Nachemson*s study 97  T h i s group c o n s i s t e d o f the p a t i e n t s a v a i l -  a b l e from a group o f 130 seen between 1927 and 1936 a t a major c e n t r e i n Sweden. tioned:  No X-rays were a v a i l a b l e .  referral  Of the 97 p a t i e n t s ques-  30 p e r c e n t were c l a i m i n g a d i s a b i l i t y p e n s i o n and the average  age a t which i t was claimed was 36.  Another  study  ( N i l s o n n e and Lundgren  1968) found almost o n e - h a l f o f the p a t i e n t s c o n t a c t e d were unable t o work.  The h i g h p r o p o r t i o n o f unmarried  Lundgren's study i s another  (76 p e r c e n t ) i n N i l s o n n e and  s t a t i s t i c which c o u l d be used t o i l l u s t r a t e  s o c i a l b e n e f i t o f e a r l y treatment and p r e v e n t i o n o f cosmetic d e f o r m i t y . Drummond e t a l . (1976) i n a Quebec study found 24 p e r c e n t unemployed w h i l e 42 p e r c e n t o f females and 30 p e r c e n t o f males were  unmarried.  I t i s important t o know t h a t the sample i n these s t u d i e s i s o f adolescent i d i o p a t h i c s c o l i o t i c s .  N i l s o n n e and Lundgren (1968) mention  t h a t s c o l i o s i s due to p a r a l y s i s and r i c k e t s were, excluded from  their  sample but t h a t some c o n g e n i t a l s c o l i o s i s may be i n a d v e r t e n t l y i n c l u d e d . As the i n c i d e n c e i s 5 p e r c e n t f o r c o n g e n i t a l s c o l i o s i s mation  this  s h o u l d n o t be s i g n i f i c a n t  i n their  esti-  to the r e s u l t s .  Nachemson i n c l u d e s u n t r e a t e d s c o l i o t i c s o f a l l types i n h i s study and o f the 130 p a t i e n t s , 59 were i d i o p a t h i c s c o l i o s i s .  I t was  p o s s i b l e to t r a c e 52 of these 59 p a t i e n t s and 10 o f t h e 52 were 75 percent d i s a b l e d .  These s t a t i s t i c s f o r d i s a b i l i t y were the lowest f o r  any o f t h e f i v e types o f s c o l i o s i s quoted  i n the sample.  T h i s study i s w i d e l y  to i l l u s t r a t e the b e n e f i t of p r e v e n t i o n i n s c o l i o s i s and so i t i s  important  to know whether s o c i a l e f f e c t s d e s c r i b e d a r e due to s c o l i o s i s  i n g e n e r a l o r to a s p e c i f i c  type.  I n the time o f these s t u d i e s t h e r e  were s c o l i o t i c s who were p o l i o c a s u a l t i e s o r r a c h i t i c .  I t would appear  from Nachemson's paper t h a t the sequelae o f i d i o p a t h i c s c o l i o s i s a r e the l e a s t  severe.  The i n f o r m a t i o n on Drummond's study does not i n d i -  c a t e whether the sample i s e x c l u s i v e l y i d i o p a t h i c s c o l i o t i c p a t i e n t s . In summary i f b e n e f i t s a r e t o be c l a i m e d on the b a s i s o f sequel a e prevented by s c r e e n i n g then s c i e n t i f i c s c r u t i n y would r e q u i r e experimental or quasi-experimental evidence. c o u l d n o t be found  i n this literature  Evidence o f t h i s  nature  survey and i t i s q u e s t i o n a b l e i f  the d e s c r i p t i v e s t u d i e s found a r e u s e f u l i n terms o f claimed b e n e f i t s for  screening f o r i d i o p a t h i c T h i s completes  scoliosis.  the a p p l i c a t i o n o f 12 s e l e c t e d c r i t e r i a to the  l i t e r a t u r e on s c o l i o s i s and s c o l i o s i s  screening.  whether the evidence j u s t i f i e s s c o l i o s i s c r i t e r i a w i l l f o l l o w i n Chapter  five.  Further discussion of  s c r e e n i n g i n terms o f these  CHAPTER I I I  METHODOLOGY  Purpose o f t h e Study T h i s study e v a l u a t e s out  t h e s c o l i o s i s s c r e e n i n g program c a r r i e d  i n SFHD t o s u b s t a n t i a t e t h a t the program should be c o n t i n u e d .  The  e v a l u a t i o n was done by a p p l y i n g e s t a b l i s h e d c r i t e r i a t o t h e outcomes o f screening  to determine t h e a c c e p t a b i l i t y o f b o t h t h e s c r e e n i n g  the treatment recommended, the v a l i d i t y o f t h e s c r e e n i n g a v a i l a b i l i t y of resources.  t e s t and  t e s t and t h e  The data from t h e study was analysed  mainly  i n r e l a t i o n t o these f o u r p r i n c i p a l c r i t e r i a b u t c o n s i d e r a t i o n was a l s o g i v e n t o the i m p l i c a t i o n s o f t h e other  important c r i t e r i a o f s c r e e n i n g  f o r c o n t i n u a t i o n o f t h e program.  D e s c r i p t i o n o f t h e Screening  Program  Time P e r i o d The 1980  time p e r i o d f o r t h i s study was from September 1976 to June  and i n c l u d e s t h e s c r e e n i n g  school years.  f o r s c o l i o s i s c a r r i e d on d u r i n g  A p i l o t p r o j e c t o f s c o l i o s i s s c r e e n i n g was conducted  d u r i n g January t o June 1976 and i n v o l v e d 775 students schools.  four  The data  from s e l e c t e d  from t h i s p i l o t program and t h e data  screened a f t e r June 1980 were not i n c l u d e d i n t h i s  from c h i l d r e n  study.  Sample To q u a l i f y f o r s c r e e n i n g  i t was r e q u i r e d t o be a student  at a  56  s c h o o l w i t h i n SFHD ( p r i v a t e or p u b l i c ) . districts: and  School D i s t r i c t #43  School D i s t r i c t  SFHD i s comprised of two s c h o o l  (Coquitlam,  #40 (New W e s t m i n s t e r ) .  1977-78, and 1978-79 only School D i s t r i c t the s c h o o l y e a r  P o r t Coquitlam, P o r t Moody) I n the s c h o o l y e a r s 1976-77,  #43 p u p i l s were screened.  1979-80 p u p i l s from New Westminster were i n c l u d e d i n the  s c r e e n i n g program.  I n s c h o o l year  1879) were screened  and a sampling o f 35 p e r c e n t  (N = 708).  In  I n the s c h o o l year  a group of 125 rechecks and n i n e s t u d e n t s ) .  1976-77 a l l grade seven p u p i l s (N = of the grade e i g h t s  1977-78 a l l grade sevens (N = 1748) and  from the p r e v i o u s  year were seen (grade  I n the 1978-79 and 1979-80 s c r e e n i n g y e a r s  grade seven s t u d e n t s were screened, grand t o t a l of p u p i l s screened i n c l u d e d i n t h e program.  eight only  1690 and 1860 r e s p e c t i v e l y .  was 8010.  Both boys and g i r l s were  No consent was r e q u i r e d f o r s c r e e n i n g .  s c h o o l p r i n c i p a l sent home an e x p l a n a t o r y n o t i f i c a t i o n o f the date of s c r e e n i n g .  these c h i l d r e n ) were excluded  The  l e t t e r about the program and  Consent was i m p l i e d i f no d i s -  s e n t i n g communication was r e c e i v e d by the time of s c r e e n i n g . dren known to have s c o l i o s i s  The  ( t h e p u b l i c h e a l t h nurse would from s c r e e n i n g .  s c r e e n i n g or f o r whom a note or telephone  A l l chilidentify  Those c h i l d r e n who  refused  message was r e c e i v e d a d v i s i n g  r e f u s a l of s c r e e n i n g were so noted on the c l a s s l i s t used by the s c r e e n i n g team.  Those a l r e a d y known as s c o l i o t i c were i n c l u d e d i n the f i g u r e s  used t o determine p r e v a l e n c e  Screening  i n this  study.  test  Each c h i l d was examined by one of the s c r e e n i n g team, which c o n s i s t e d t o two p u b l i c h e a l t h nurses and a p h y s i o t h e r a p i s t .  There  57  were f o u r to s i x p u b l i c h e a l t h nurses and r o t a t i n g on the teams. from an o r t h o p e d i c nurses,  The  three  physiotherapists  p h y s i o t h e r a p i s t s had  received  training  surgeon at the time of the p i l o t p r o j e c t .  some of whom were new  the p h y s i o t h e r a p i s t s and  to s c r e e n i n g  by use  The  each year were t r a i n e d by  of a t r a i n i n g f i l m produced by  the  S c o l i o s i s Research S o c i e t y . The  examination c o n s i s t e d of v i e w i n g  top c l o t h i n g removed.  equal level,  crests.  The  arms a t s i d e s .  l e v e l of i n f e r i o r angles  The  examiner n o t e d :  of s c a p u l a , w a i s t  l e v e l , dorsal superior i l i a c  s p i n e l e v e l , and  seventh c e r v i c a l v e r t e b r a e .  Next the c h i l d was  ward f l e x e d , w i t h hands c l a s p e d straight. region.  The The  c h i l d was  e r e c t , f a c i n g away from the examiner w i t h  on both f e e t and  shoes  G i r l s c o u l d wear h a l t e r s or b r a s s i e r e s .  were lowered to the l e v e l of the i l i a c examined s t a n d i n g  the c h i l d w i t h  angles,  plumb bob  Pants first  weight shoulder  iliac  crest  alignment from  examined s t a n d i n g ,  i n f r o n t , head w e l l f l e x e d and  examiner then noted the l e v e l of t h o r a c i c and  s c r e e n e r was  and  for-  knees  lumbar  l o o k i n g f o r a r a i s e d a r e a at the s i d e of  the  s p i n e which i s the c l a s s i c r i b hump of t h o r a c i c s c o l i o s i s .  C r i t e r i a for r e f e r r a l Any iosis: waist  one  of the f o l l o w i n g was  considered  a p o s i t i v e s i g n of  presence of a t h o r a c i c and/or lumbar e l e v a t i o n , s h i f t of a n g l e change, p e l v i c asymmetry, one  c a f e au l a i t  spots  (neurofibromatosis).  s i s t e n t l y i n a l l years  prominent s h o u l d e r  spine,  b l a d e or  These s t a n d a r d s were used con-  of s c r e e n i n g under c o n s i d e r a t i o n i n t h i s  A s c r e e n i n g p o s i t i v e was  scol-  a student  with  one  study.  of the s i g n s of  s c o l i o s i s which had been confirmed d u r i n g r e s c r e e n i n g  two  days  later  58  by another p h y s i o t h e r a p i s t . Upon the d e c i s i o n t o l a b e l the c h i l d as positive,  a l e t t e r was m a i l e d t o the p a r e n t .  h e a l t h nurse telephoned give reassurance.  The d i s t r i c t  public  the p a r e n t s to e x p l a i n the recommendations and  T h i s c a l l was made on the day of the r e s c r e e n i n g ,  i n the evening i f n e c e s s a r y .  Referral  procedure Accompanying the l e t t e r to the p a r e n t was a l e t t e r from the  p h y s i c i a n to be p r e s e n t e d t o him by the parent a t time of the m e d i c a l examination.  The f a m i l y d o c t o r was r e q u e s t e d t o :  a) re-examine the c h i l d , e s p e c i a l l y  i n forward  flexion  b) have a s t a n d i n g X-ray done i f t h e r e was agreement .with the findings c) r e f e r t o an o r t h o p e d i c surgeon i s s i g n s were confirmed on X-ray. The p h y s i c i a n was r e q u e s t e d t o w r i t e h i s f i n d i n g s on the back of  the l e t t e r of r e f e r r a l and m a i l h i s r e p l y i n the stamped  addressed  envelope p r o v i d e d by the h e a l t h d i s t r i c t . When the p i l o t program was i n i t i a t e d an o r t h o p e d i c surgeon was actively  i n v o l v e d i n the p l a n n i n g s t a g e s .  p e d i c surgeons agreed  working  i n the h e a l t h d i s t r i c t a t which time i t was  t h a t one o f them, an o r t h o p e d i c surgeon, would take primary  responsibility  for referrals  cussed a t a meeting  t h i s agreement.  of s c r e e n i n g under  from the program.  T h i s d e c i s i o n was d i s -  of the New Westminster M e d i c a l S o c i e t y so t h a t  general p r a c t i t i o n e r s of  A meeting was h e l d of o r t h o -  who made r e f e r r a l s  to o r t h o p e d i s t s would be aware  T h i s i n f o r m a l p o l i c y was i n e f f e c t d u r i n g the p e r i o d review.  59 Confirmed p o s i t i v e s The  presence of a curve  thoracic-lumbar  g r e a t e r than 10°  a n t e r i o r - p o s t e r i o r X-ray was  p o s i t i v e f o r the purpose of t h i s study. c o n f i r m a t i o n of " s c o l i o s i s — t o be  (Cobb method) on a  considered o r t h o p e d i c a l l y  As w e l l any  f o l l o w e d " was  u n t i l X-ray c o n f i r m a t i o n of the degree of  orthopedist's  considered p o s i t i v e  curvature.  Program d a t a C l a s s l i s t s were used d u r i n g s c r e e n i n g so t h a t every examined was lists  recorded.  as were absentees.  the day  of r e s c r e e n i n g .  n u r s e c o n t a c t of p a r e n t s by  Any  s c r e e n i n g r e f u s a l s were noted on  There was  these  an attempt to s c r e e n absentees  From the p h y s i c i a n r e p o r t s and and  child  public health  p h y s i c i a n s , a r e c o r d card was  the p h y s i o t h e r a p i s t s f o r each c h i l d who  initially  on  completed  failed  screening.  For the p e r i o d of t h i s study  169  s c r e e n i n g p o s i t i v e s have been  fied.  169  c h i l d r e n were examined f o r complete-  The  r e c o r d s f o r these  ness of outcome i n f o r m a t i o n . m a t i o n noted and  For 47 c h i l d r e n t h e r e was  no f u r t h e r c o n t a c t was  identi-  complete  infor-  necessary.  Study Method The  r e c o r d cards f o r the remainder  checked f o r an u p - t o - d a t e address and r e c o r d s , telephone used to c o n f i r m address was mation was  book, student  the l o c a t i o n .  (122)  were s c r u t i n i z e d and  phone number.  d i r e c t o r i e s and  Health  District  s c h o o l r e c o r d s were  There were f i v e cases where a c u r r e n t  not a v a i l a b l e , however, i n each case enough outcome i n f o r a v a i l a b l e from i n i t i a l h e a l t h d i s t r i c t  them i n the sample.  The  new  contact  addresses of t h r e e cases  to i n c l u d e  away from  the  60  d i s t r i c t were a v a i l a b l e and these p a r e n t s were c o n t a c t e d by l e t t e r and asked t o r e p l y t o t h e same q u e s t i o n s posed A l l replied  i n the telephone i n t e r v i e w .  i n c l u d i n g a family traced to C a l i f o r n i a .  For those 114 cases i n which i n f o r m a t i o n was incomplete and an address was a v a i l a b l e t h e f o l l o w i n g procedure was f o l l o w e d : 1) F i r s t a l e t t e r of i n t r o d u c t i o n from SFHD was s e n t t o the p a r e n t s of t h e 114 c h i l d r e n  (Appendix A) b e f o r e any c o n t a c t was made.  2) One week f o l l o w i n g the m a i l i n g o f these l e t t e r s i n t e r v i e w s began, d u r i n g which p a r e n t s were asked about of the r e f e r r a l of t h e i r c h i l d the i n t e r v i e w f o r m a t ) .  telephone  the outcomes  f o l l o w i n g s c r e e n i n g (Appendix B o u t l i n e s  A l l p a r e n t s cooperated by g i v i n g i n f o r m a t i o n .  From these i n t e r v i e w s r e c o r d s f o r 68 c h i l d r e n were  completed.  3) For the r e m a i n i n g 46 c h i l d r e n a c o n t a c t t o the p h y s i c i a n was n e c e s s a r y t o complete  the outcome i n f o r m a t i o n .  The p a r e n t s were asked  at the time of the telephone i n t e r v i e w i f they consented contact.  A consent  (Appendix  to p h y s i c i a n  C) was m a i l e d w i t h an e n c l o s e d stamped  addressed envelope t o the 46 f a m i l i e s . 4) P r i o r t o the i n v e s t i g a t o r c o n t a c t i n g the p h y s i c i a n a l e t t e r of i n t r o d u c t i o n was m a i l e d from SFHD (Appendix D).  The purpose of t h i s  l e t t e r was t o e x p l a i n the o b j e c t i v e o f the s c o l i o s i s program e v a l u a t i o n and  encourage  p h y s i c i a n c o o p e r a t i o n i n completing the q u e s t i o n n a i r e .  5) As the p a r e n t a l consents were r e c e i v e d they were m a i l e d a l o n g w i t h the q u e s t i o n n a i r e to each p h y s i c i a n stamped addressed envelope f o r the r e p l y .  (Appendix E ) , i n c l u d i n g a The o r t h o p e d i c s p e c i a l i s t  who r e c e i v e d the m a j o r i t y o f r e f e r r a l s from the f a m i l y d o c t o r s was cont a c t e d d i r e c t l y and an arrangement made to work d i r e c t l y i n h i s m e d i c a l records  system.  61 At t h i s p o i n t i n the study a p o s t s c r i p t was  a m a i l s t r i k e was  added to the q u e s t i o n n a i r e  p l e t e d q u e s t i o n n a i r e would be arranged  threatened  t h a t pickup  upon a telephone  and  so  of the comcall  to  the  investigator.  C a l c u l a t i o n of Resources Used Resources r e q u i r e d f o r a s c r e e n i n g program i n c l u d e the to  c a r r y out  the s c r e e n i n g procedure i t s e l f  n o s i s and  treatment as necessary  program.  To d e s c r i b e r e s o u r c e s  in  the s c r e e n i n g program was  h e a l t h nurses and  and  to those who utilized,  those  a r e r e f e r r e d from  the amount of s t a f f  to each program y e a r .  and  treatment r e s o u r c e s were c a t e g o r i z e d as m e d i c a l ,  and  physiotherapy.  diag-  the  time used  Diagnostic  X-ray, o r t h o t i c  From the i n f o r m a t i o n g i v e n i n the i n t e r v i e w s  and  problems encountered i n o b t a i n i n g s e r v i c e s i n any  of the n e c e s s a r y  areas; medical,  documented.  r e s u l t i n g t a b u l a t i o n s a r e presented  The  that provide  tabulated for physiotherapists, p u b l i c  c l e r k s , according  q u e s t i o n n a i r e s any  resources  X-ray, o r t h o t i c or p h y s i o t h e r a p y ,  were  i n Chapter f o u r .  Because t h e r e a r e i m p l i c a t i o n s f o r p r o v i n c e - w i d e a p p l i c a t i o n of s c r e e n i n g was  determined.  l i s h e d by and  the l o c a t i o n of o r t h o p e d i c  t i s t s was  orthotists in  B.C.  To o b t a i n t h i s i n f o r m a t i o n the M e d i c a l D i r e c t o r y pub-  the C o l l e g e of P h y s i c i a n s and  the l i s t  surgeons and  Surgeons of B r i t i s h  of C e r t i f i e d O r t h o t i s t s of the B.C.  consulted.  Columbia  A s s o c i a t i o n of O r t h o -  These d a t a a r e a l s o found i n Chapter f o u r .  Economic e v a l u a t i o n It  i s accepted  t h a t e v a l u a t i o n of evidence  that a  screening  measure i s e f f e c t i v e should precede economic e v a l u a t i o n of the program  62  (McKeown and Knox 1968; S a c k e t t 1975a).  The q u e s t i o n o f e f f e c t i v e n e s s  of the s c r e e n i n g measure ( t h a t i s , i t s v a l i d i t y ) i s t o be assessed i n t h i s study, as w e l l as i t s a c c e p t a b i l i t y and the a c c e p t a b i l i t y of the treatment  f o r the c o n d i t i o n .  There i s no p o i n t i n economic e v a l u a t i o n  o f a measure which i s not v a l i d nor a c c e p t a b l e , or which r e s u l t s i n d e t e c t i o n o f a c o n d i t i o n f o r which no a c c e p t a b l e treatment  exists.  For t h i s r e a s o n a complete economic e v a l u a t i o n i s n o t attempted. the time used by h e a l t h d i s t r i c t presented  under the d i s c u s s i o n of a v a i l a b i l i t y  (see Chapter f o u r ) . district  s t a f f has been estimated  and data i s resources  Such t a b u l a t i o n may prove u s e f u l t o the h e a l t h  i n p l a n n i n g the deployment of s t a f f .  are considered  of program  Instead  I f program a l t e r n a t i v e s  i n f o r m a t i o n about the amount of time a v a i l a b l e from  c a n c e l l a t i o n of s c o l i o s i s s c r e e n i n g c o u l d be h e l p f u l .  The c o s t o f the  s c r e e n i n g program d e r i v e d by m u l t i p l y i n g the u n i t c o s t s by the number o f s e r v i c e s has been estimated  t o p r o v i d e some measures o f the d i r e c t  c o s t of the s c r e e n i n g procedure and f o r the c o s t of d i a g n o s t i c and treatment  s e r v i c e s r e s u l t i n g from s c r e e n i n g , f o r both s c r e e n i n g  posi-  t i v e s and n e g a t i v e s .  Methods of A n a l y s i n g Program Data To determine the outcomes of s c o l i o s i s s c r e e n i n g f o r the p e r i o d under review ing.  Class  t h i s i n v e s t i g a t o r examined a l l a v a i l a b l e r e s u l t s of s c r e e n -  The d a t a was reviewed as f o l l o w s .  lists Each l i s t was examined t o determine the number o f c h i l d r e n  screened  and the number noted  as s c r e e n i n g  refusals.  Record  cards The  i n v e s t i g a t o r reviewed each of the s c r e e n i n g p o s i t i v e s and  t a b u l a t e d the t o t a l number and the number o f : 1) r e f u s a l s f o r r e f e r r a l a t any l e v e l 2) r e f e r r a l s  to f a m i l y  doctor  3) r e f e r r a l s t o o r t h o p e d i c  surgeon  4) c h i l d r e n X-rayed by f a m i l y d o c t o r and by o r t h o p e d i s t 5) c h i l d r e n who were s c r e e n i n g p o s i t i v e and o r t h o p e d i c a l l y negative  ( l e s s than 11° curve) 6) c h i l d r e n who were o r t h o p e d i c a l l y p o s i t i v e ( g r e a t e r than 10°) 7) c h i l d r e n who were a l r e a d y known t o have s c o l i o s i s 8) c h i l d r e n w i t h  other s p i n a l d i s e a s e  9) unknown outcomes The  orthopedic  1) the i n i t i a l and  p o s i t i v e s were analysed  curve and number remaining  stable, progressing  decreasing 2) the f o l l o w - u p  surgery, at  and a r e d e s c r i b e d by:  and other  received - observation, physiotherapy,  bracing,  such as c h i r o p r a c t i c e s e r v i c e s , and non-acceptance  any l e v e l 3) d i s t r i b u t i o n by sex  Quantitative analysis Data c o l l e c t e d from a l l sources  including class l i s t s ,  record  c a r d s , i n t e r v i e w s , q u e s t i o n n a i r e s , p r e v i o u s h e a l t h d i s t r i c t r e p o r t s on s c o l i o s i s , S t a t i s t i c s Canada, M i n i s t r y of H e a l t h , Research D i v i s i o n , Medical and  D i r e c t o r i e s and o t h e r a r e c a t e g o r i z e d and presented  n a r r a t i v e form i n Chapter f o u r .  i n tables  64  The  fourfold  table  Using  the g e n e r a l l y accepted  F i g u r e 2, Grant  (1974) has  fourfold  table i l l u s t r a t e d  in  c o n s t r u c t e d a model from which u s e f u l e v a l -  u a t i v e i n d i c e s can be c a l c u l a t e d .  DIAGNOSIS Screening  Results  Total  Nondiseased  Diseased  Positive  a  b  a+ b  Negative  c  d  c+ d  a + c  b + d  Total  Fig. 2.—Fourfold  The  a + b + c + d  t a b l e c l a s s i f y i n g p a r t i c i p a n t s i n a s c r e e n i n g program.  s u b j e c t s i n the p r e c e d i n g  t a b l e are c l a s s i f i e d  a = t r u e p o s i t i v e s , d i s e a s e d persons d e t e c t e d by b = f a l s e p o s i t i v e s , nondiseased  persons screened  as f o l l o w s :  screen positive  c = f a l s e n e g a t i v e s , d i s e a s e d persons not d e t e c t e d by d = t r u e n e g a t i v e s , nondiseased  S t a t u s of s c r e e n i n g  negative  negatives  Grant suggests  t h a t to overcome the d e f i c i t  the s t a t u s of the s c r e e n i n g n e g a t i v e s or nondiseased) a technique analysis.  persons screened  screen  i n i n f o r m a t i o n about  ( t h a t i s , whether they a r e  diseased  be borrowed from the methodology of systems  A "research estimate"  i s the key  to t h e * q u a n t i t i t e s " c " and  "d". Of Grant,  the f o u r methods f o r e s t i m a t i n g d i s e a s e p r e v a l e n c e  a prevalence  estimate  g r a p h i c a l l y comparable was  from another  the one  study  listed  on a p o p u l a t i o n demo-  chosen f o r t h i s a n a l y s i s .  The  by  p r o s p e c t i v e study of Rogala The proposed  e t a l . (1978) was s e l e c t e d f o r t h i s  model i s summarized i n F i g u r e 3.  purpose.  The key, the t o t a l number  d i s e a s e d i n the p o p u l a t i o n (a + c) i s o b t a i n e d by m u l t i p l y i n g the t o t a l screened by the p r e v a l e n c e e s t i m a t e o b t a i n e d from other s t u d i e s .  )  Step 2 Classification of s c r e e n p o s i t i v e s by c l i n i c a l d i a g n o s i s  c  a + c  b + d  a-fcb+c+d  Step 3 E s t i m a t i o n of disease prevalence  C l a s s i f i c a t i o n of the p o p u l a t i o n by s c r e e n i n g  Fig.  table.  3 . — A n a l y t i c a l d e r i v a t i o n o f the f o u r f o l d  SOURCE:  John A. Grant, " Q u a n t i t a t i v e E v a l u a t i o n of a S c r e e n i n g Program," AJPH, Jan. 1974, 64:1, p. 69.  A p p l i c a t i o n of the model U s i n g the p r e v a l e n c e e s t i m a t e of the d i s e a s e to c a l c u l a t e d i s e a s e d as proposed  by Grant a l l o w s completion of a f o u r f o l d  total  t a b l e and  c a l c u l a t i o n of the measures of v a l i d i t y . 1) The model was used  to e v a l u a t e s e n s i t i v i t y —  f  a  +  J  p r o p o r t i o n o f the t r u l y d i s e a s e d who were c o r r e c t l y 2) The model was used  the  identified.  to e v a l u a t e s p e c i f i c i t y ^'  p r o p o r t i o n of the t r u l y non-diseased  — , i.e. c  who were c o r r e c t l y  > i.e. identified.  the  66 3) The model was used false positives,i.e.  o v e r r e f e r r a l —7—r- , or a + b the r a t i o o f non-diseased persons w i t h p o s i t i v e  s c r e e n s t o a l l those  referred.  4) The model was used  to determine  t o determine  underreferral  f a l s e n e g a t i v e s , i . e . t h e r a t i o o f d i s e a s e d persons w i t h  ;—- , or c + d negative  s c r e e n to a l l those n o t r e f e r r e d . 5) The model was used  a a  t o determine  the p o s i t i v e p r e d i c t i v e value  j- , the p r o b a b i l i t y t h a t a p a t i e n t w i t h a p o s i t i v e s c r e e n i n g t e s t i s  diseased. 6) The model was used  to determine  the t o t a l p r e d i c t i v e v a l u e  a + d  ;—7  —7-7-—;  , the p r o b a b i l i t y  t h a t the t e s t c o r r e c t l y i d e n t i f i e s the  a + b + c + d r e c i p i e n t (both p o s i t i v e s and n e g a t i v e s ) . E t h i c a l Review A r e q u e s t f o r e t h i c a l review of a c t i v i t i e s i n v o l v i n g human subj e c t s i n q u e s t i o n n a i r e s , i n t e r v i e w s , o b s e r v a t i o n s , t e s t i n g , v i d e o and audio  tapes, e t c . was submitted  to the U n i v e r s i t y o f B r i t i s h  Columbia  S c r e e n i n g Committee f o r Research  and Other  Subjects:  P e r m i s s i o n t o proceed w i t h the study  Behavioural Sciences.  S t u d i e s I n v o l v i n g Human  was r e c e i v e d (Appendix F ) . The by  telephone  i n t e r v i e w s and q u e s t i o n n a i r e s were a d m i n i s t e r e d  the i n v e s t i g a t o r w h i l e on e d u c a t i o n a l l e a v e from h e r p o s i t i o n as  n u r s i n g s u p e r v i s o r o f the Simon F r a s e r H e a l t h D i s t r i c t .  She i s an  e x p e r i e n c e d p u b l i c h e a l t h nurse who i s f a m i l i a r w i t h the i n t e r v i e w i n g p r o c e s s and the need f o r r e s p e c t of c o n f i d e n t i a l i t y i n the g a t h e r i n g of d a t a from i n d i v i d u a l s . of H e a l t h f o r t h i s study  She has the endorsement o f t h e Deputy M i n i s t e r (Appendix G).  CHAPTER IV  RESULTS OF THE  SCREENING PROGRAM  The r e s u l t s of s c o l i o s i s s c r e e n i n g w i l l be p r e s e n t e d  relative  to the f o u r p r i n c i p a l c r i t e r i a which have been s e l e c t e d f o r t h i s  study  as most u s e f u l i n e v a l u a t i o n of the program a t Simon F r a s e r H e a l t h District.  A c c e p t a b i l i t y o f the S c r e e n i n g T e s t To a s s e s s the a c c e p t a b i l i t y of the s c r e e n i n g t e s t to the  popula-  t i o n c o n s i d e r a t i o n w i l l be g i v e n to a c c e p t a b i l i t y of the t e s t to 1) e n t s , 2) c h i l d  screened and  par-  3) p h y s i c i a n s .  1) A c c e p t a b i l i t y to p a r e n t s A measure of the a c c e p t a b i l i t y of s c r e e n i n g to p a r e n t s i s the p r o p o r t i o n of r e f u s a l s to consent  to s c r e e n i n g of t h e i r  child.  As mentioned p r e v i o u s l y the s c h o o l c l a s s l i s t s were and  the number o f c h i l d r e n who  w i t h the reason i f one was als  searched  were exempted from s c r e e n i n g noted  given.  Of 8031  along  c h i l d r e n a t o t a l of 21  refus-  (0.3 p e r c e n t ) were r e c e i v e d i n the f o u r y e a r s of the s c r e e n i n g  program under review.  In n i n e cases the reason g i v e n was  problem under m e d i c a l c a r e .  Two  a spinal  exemptions were a l s o asked  t h a t the f a m i l y c h i r o p r a c t o r would check the c h i l d ' s : s p i n e . cases no reason was  given.  on the b a s i s In t e n  The r e s u l t s are t a b u l a t e d i n T a b l e I I .  68  TABLE I I REFUSAL OF CONSENT FOR  SCREENING  reason number screened  known problem  t o t a l of refusals  for refusal  chiropractor would s c r e e n  no  reason given  1967-77  2587  2  -  -  2  1977-78  1873  9  4  2  3  1978-79  1690  5  2  -  3  1979-80  1860  5  3  -  2  Total  8010  21  9  2  10  During  the 114  telephone  i n t e r v i e w s c a r r i e d out by t h i s  gator to complete data on s c r e e n i n g outcomes, w i t h few was  widespread endorsement by p a r e n t s  parent  criticized  investi-  exceptions  there  of the s c r e e n i n g program.  One  the n o t i f i c a t i o n p r o c e s s , as she had been, shocked by  the a r r i v a l of the l e t t e r a d v i s i n g r e f e r r a l .  She had  not r e c e i v e d a  phone c a l l of e x p l a n a t i o n b e f o r e the l e t t e r ' s a r r i v a l as i s the recommended h e a l t h d i s t r i c t  practice.  When the program was 1978  evaluated  f o r a c c e p t a b i l i t y i n 1977  some p a r e n t s  f e l t more e x p l a n a t i o n about the d i s e a s e of  would be h e l p f u l .  Subsequently the h e a l t h d i s t r i c t p r o v i d e d  and  scoliosis school  p r i n c i p a l s w i t h a model l e t t e r e x p l a i n i n g the program and a b r i e f c r i p t i o n of s c o l i o s i s which c o u l d be d i s t r i b u t e d at the time of c a t i o n of the s c r e e n i n g  date.  des-  notifi-  69  2) A c c e p t a b i l i t y t o t h e c h i l d  screened  Only one documentation of r e f u s a l t o be screened (N = 8022) i s noted on survey has  reported  of t h e c l a s s l i s t s .  The s c r e e n i n g  team  t h a t s e l f - c o n s c i o u s g i g g l i n g and remarks were common d u r i n g  the s c r e e n i n g p r o c e d u r e .  A t t i t u d e s appeared t o be improved w i t h t h e  i n t r o d u c t i o n of a s h o r t e x p l a n a t o r y p r i o r t o the s c r e e n i n g s e s s i o n .  t a l k by t h e s c h o o l nurse a few days  The c h i l d r e n were t o l d what t o expect  of s c r e e n i n g and what wearing a p p a r e l was s u i t a b l e . been assessed considered  by t h e p u p i l  Absentee r a t e has  and was normal a t t h e time o f s c r e e n i n g .  as an u n o b t r u s i v e  T h i s can be  measure o f t h e a c c e p t a b i l i t y o f t h e s c r e e n -  i n g procedure. When parents  (N = 114) were i n t e r v i e w e d d u r i n g t h i s study  commented on t h e a n x i e t y e x p e r i e n c e d r e s c r e e n i n g examination a t s c h o o l .  by t h e i r c h i l d r e n due t o t h e I n one case t h e c h i l d had a f r i e n d  who had j u s t had s u r g e r y f o r s c o l i o s i s and he was v e r y During  previous  three  apprehensive.  e v a l u a t i o n of the s c r e e n i n g program when a  p u b l i c h e a l t h nurse v i s i t e d a random sample of f a m i l i e s (N = 31) t o ask t h e i r r e a c t i o n to the program n i n e  (29 p e r c e n t )  daughters were v e r y s e l f - c o n s c i o u s about b e i n g personnel  mentioned t h a t  their  examined by h e a l t h u n i t  (Ladner 1978).  3) A c c e p t a b i l i t y to the p h y s i c i a n s When a sample of t e n p h y s i c i a n s was i n t e r v i e w e d by the A s s i s t a n t M e d i c a l H e a l t h O f f i c e r i n 1977 a l l i n d i c a t e d a p p r o v a l  of t h e program.  These ten were s e l e c t e d randomly from those p h y s i c i a n s r e c e i v e d a r e f e r r a l from the program d u r i n g s c h o o l year  (N = 82) who had 1976-77.  In  two  i n s t a n c e s (2 p e r c e n t ) d u r i n g the study i n t e r v i e w s (N = 114) t o com-  p l e t e d a t a f o r t h i s study p a r e n t s r e p o r t e d t h e comment o f t h e i r  physi-  c i a n t h a t the r e f e r r a l had been a "waste of time".  A c c e p t a b i l i t y of Treatment Treatment  alternatives  There were f i v e approaches  t o treatment documented a f t e r a c h i l d  was diagnosed i n t h i s program as s c o l i o t i c : i n t e r v a l s , 2) placement  1) o b s e r v a t i o n a t r e g u l a r  on an e x e r c i s e program under p h y s i o t h e r a p i s t  s u p e r v i s i o n , 3) b r a c i n g , 4) s u r g e r y , or 5) o t h e r c a r e such as c h i r o practic.  The same c h i l d c o u l d p r o g r e s s from one c a t e g o r y t o another  as a r e s u l t o f change i n the curve and treatment might be r e f u s e d a t any s t a g e .  The f o l l o w i n g t a b l e  (Table I I I ) i l l u s t r a t e s  u t i l i z e d by those c h i l d r e n who were diagnosed  the treatments  scoliotic.  TABLE I I I TREATMENT OF ORTHOPEDIC POSITIVE CHILDREN  year  total  observed • only  physio  brace  surgery  other*  1976-77  17  9  8  1  3  1  1977-78  14  10  2  2  -  -  1978-79  5  2  -  2  3  1  1979-80  4  3  -  1  -  -  40  24  10  6  6  2  Total  * C h i r o p r a c t i c c a r e i n these cases  (self-referral).  71  1) O b s e r v a t i o n i n c l u d e s those c h i l d r e n under the s u p e r v i s i o n of e i t h e r the f a m i l y p h y s i c i a n or the o r t h o p e d i c s p e c i a l i s t .  Children i n  t h i s c a t e g o r y a r e presumed " a t r i s k " f o r a p r o g r e s s i v e curve because they had  a curve g r e a t e r than 10° and were s k e l e t a l l y immature.  were seen a t i n t e r v a l s of from t h r e e months to one y e a r , w i t h examination on some o r a l l v i s i t s .  The number f a i l i n g  the recommendation f o r o b s e r v a t i o n are noted  They  X-ray  t o comply w i t h  i n T a b l e IV.  2) Phys i o therapy i n the t e n cases t r e a t e d by t h i s means a l o n e , u s u a l l y i n v o l v e d a continuous program of e x e r c i s e s under the s u p e r v i s i o n of a p h y s i o t h e r a p i s t i n a c l i n i c a l s e t t i n g r e n t w i t h a home program.  ( h o s p i t a l or o f f i c e )  concur-  Royal Columbian H o s p i t a l o f f e r e d a t r i - w e e k l y  program of group p h y s i o t h e r a p y f o r s c o l i o s i s p a t i e n t s and e i g h t of the ten p a t i e n t s attended t h i s program. t r e a t e d f o r over two y e a r s .  Others have had s h o r t e r p e r i o d s of  ment (two months to s i x months). p h y s i o t h e r a p y was  Some of the c h i l d r e n have been treat-  The recommendation f o r treatment  by  accepted i n a l l c a s e s .  3) Brace treatment was  p r e s c r i b e d f o r nine c h i l d r e n .  r e f u s e d b r a c i n g and o f these, two have had s u r g e r y . a 38° curve and i s under c h i r o p r a c t i c c a r e . were b r a c e d one c h i l d was  The  Three  third g i r l  Of the s i x c h i l d r e n  has  who  f i t t e d and wore her Milwaukee b r a c e o n l y a  few hours b e f o r e r e j e c t i n g i t c o m p l e t e l y .  She r e q u i r e d s u r g i c a l c o r -  r e c t i o n one year l a t e r and r e c e i v e d c h i r o p r a c t i c treatment d u r i n g the intervening year.  Two  c h i l d r e n each wore t h e i r b r a c e s f o r about  months but t h e i r curves p r o g r e s s e d to the degree Rod  and s p i n a l f u s i o n ) was  required.  b r a c e s one began b r a c e treatment  15  that s u r g e r y ( H a r r i n g t o n  Of the remaining t h r e e g i r l s i n  i n September 1980  (10 months ago)  and  72  has been m a i n t a i n e d s u c c e s s f u l l y .  She  every t h r e e months and i s X-rayed is  i s seen by the o r t h o p e d i c surgeon  on every second v i s i t .  r e p o r t e d as " h o l d i n g s t e a d y " and  i t i s anticipated  her b r a c e a t l e a s t u n t i l September 1982. i n a b r a c e s i n c e January 1979 of  Another  f o r a 28° curve.  b r a c e treatment the curve has reduced  a y e a r a f t e r r e f e r r a l from s c r e e n i n g .  The  c h i l d has been m a i n t a i n e d  I n the two  referred  and a h a l f y e a r s  She was  to an o r t h o p e d i c surgeon who  i s now  being  t h i r d g i r l moved to C a l i f o r under o b s e r v a t i o n of  h e r f a m i l y d o c t o r p r i o r t o her move but no X-ray was she was  27°  t h a t she w i l l be i n  to 16° and the g i r l  weaned from the b r a c e e i g h t hours d a i l y . nia  Her c u r v e of  taken.  In C a l i f o r n i a  p l a c e d her i n a m o d i f i e d  b r a c e f i t t e d below the s h o u l d e r b l a d e s to h i p l i n e .  Her mother w r i t e s t h a t  she i s seen every f o u r months w i t h X-rays and t h a t she does e x e r c i s e s d a i l y . S u r g i c a l c o r r e c t i o n was of  a H a r r i n g t o n Rod  c a r r i e d out on s i x g i r l s who  and subsequent  spinal fusion.  two of t h i s c a t e g o r y were b r a c e f a i l u r e s and r e m a i n i n g case was brace.  had  As mentioned  placement previously  three r e j e c t e d b r a c i n g .  The  not c o n s i d e r e d s u i t a b l e f o r c o r r e c t i o n by the Milwaukee  A l l the c o r r e c t i o n s a r e r e p o r t e d to be s u c c e s s f u l .  wearing a b r a c e p o s t - o p e r a t i v e l y  One  girl is  ( f o r s i x months) and another w i l l have a  p o r t i o n of the rod removed because  i t has become troublesome.  Surgery  was  r e f u s e d by t h r e e g i r l s . The and  t o t a l resources u t i l i z e d  f o r those who  f o r these o r t h o p e d i c p o s i t i v e  cases  were s c r e e n i n g p o s i t i v e but o r t h o p e d i c a l l y n e g a t i v e , w i l l  be d i s c u s s e d i n d e t a i l under the a v a i l a b i l i t y of r e s o u r c e s .  Refusals.of r e f e r r a l For ing  recommendation  a s u c c e s s f u l s c r e e n i n g program b e s i d e s acceptance of the s c r e e n -  t e s t t h e r e must be acceptance of the recommendations which f o l l o w f o r  those who a r e determined  to be a s c r e e n i n g p o s i t i v e .  stages a t which t h e r e may be non-compliance. to  F i r s t t h e r e may be r e f u s a l  o b t a i n a m e d i c a l assessment as recommended.  the 169 i n t h i s study.  There a r e s e v e r a l  T h i s o c c u r r e d i n 2 of  Of those who do see t h e i r f a m i l y p h y s i c i a n a  c e r t a i n number w i l l f a i l  t o f o l l o w h i s recommendations f o r c o n t i n u e d  o b s e r v a t i o n , 2 o f the 37 a r e i n t h i s c a t e g o r y .  A t a f u r t h e r s t a g e , the  o r t h o p e d i s t w i l l recommend a c e r t a i n course of a c t i o n f o r those who a r e r e f e r r e d for  modes), d i s r e g a r d e d  the recommendation made.  I n the m a j o r i t y  those cases the curve had been minor and n o n - p r o g r e s s i v e .  gave " c o n c e r n about unnecessary ing  a r a t e of 25 p e r c e n t (65  o b s e r v a t i o n , 9 f o r b r a c i n g , 9 f o r s u r g e r y w i t h one g i r l r e f u s i n g two  treatment of  to him, 20 of the 82 e l i g i b l e ,  children  t o the o r t h o p e d i c  One mother  r a d i a t i o n " as the reason f o r not r e t u r n -  specialist.  T a b l e IV o u t l i n e s  the l e v e l s and numbers f o r non-compliance.  TABLE IV REFUSAL OF REFERRAL RECOMMENDATION  total  f a i l e d to complete observation refused ( f a m i l y Dr.) referral (N = 169) (N = 37)  7  2*  3*  1  6  -  -  -  1  2  -  1  1  1  -  -  2  2  15  4  3  1976-77  84  1  1977-78  42  -  1978-79  17  1979-80  26 169  Total  f a i l e d to complete refused observation refused surgery b r a c e (specialist) (N = 9) (N = 9) (N = 65)  *0ne of the b r a c i n g r e f u s a l s had a p r o g r e s s i v e curve, s u r g e r y was recommended and r e f u s e d .  then  P h y s i o t h e r a p y was not t a b u l a t e d as t h e r e were no known r e f u s a l s i n the 10 cases t r e a t e d by t h i s means a l o n e .  74  V a l i d i t y of the T e s t The v a l i d i t y  of the s c r e e n i n g t e s t i s e v a l u a t e d by i t s a b i l i t y  to c o r r e c t l y i d e n t i f y c h i l d r e n who have the d i s e a s e and those who do not.  I n o r d e r t o a s s e s s v a l i d i t y one must know 1) the s c r e e n i n g  t i v e s and n e g a t i v e s , 2) the d i a g n o s t i c p o s i t i v e s ( c a l l e d p o s i t i v e s i n t h i s study) and n e g a t i v e s , and 3) the t r u e From t h i s i n f o r m a t i o n a f o u r f o l d  prevalence  prevalence.  sensitivity,  o v e r r e f e r r a l and u n d e r r e f e r r a l r a t e s and the p r e d i c t i v e  v a l u e of the t e s t , u s i n g the method of Grant The  orthopedic  t a b l e i s c o n s t r u c t e d which  a l l o w s c a l c u l a t i o n of r e c o g n i z e d measures of v a l i d i t y ; specificity,  posi-  last  (see Chapter t h r e e ) .  c o n s i d e r a t i o n of v a l i d i t y w i l l be a d e r i v a t i o n of the  r a t e o f s c o l i o s i s i n the SFHD s c r e e n i n g p o p u l a t i o n .  T a b l e V g i v e s the r e s u l t s of the s c r e e n i n g t e s t s and the d i a g n o s t i c t e s t s w i t h t a b u l a t i o n of the p o s i t i v e s and n e g a t i v e s .  TABLE V RESULTS OF SCOLIOSIS SCREENING 1976-1980 IN SFHD  SCREENING TEST year  DIAGNOSTIC TEST  number orthopedic orthopedic negative unknown o t h e r * * screened p o s i t i v e n e g a t i v e p o s i t i v e  1976-77  2587  84  2503  17  65  1  1  1977-78  1873  42  1831  14 (+1)*  27  -  -  1978-79  1690  17  1673  5 (+1)*  9  -  2  1979-80  1860  26  1834  4  20  1  1  Total  8010  169  7841  121  2  4  40 (+2)  "  * O r t h o p e d i c a l l y p o s i t i v e but p r e v i o u s l y i d e n t i f i e d and under c a r e . **0ther  spinal  disease.  75  1) S c r e e n i n g p o s i t i v e s and n e g a t i v e s There were a t o t a l of 8010 c h i l d r e n screened y e a r s of the program a t SFHD.  d u r i n g the f o u r  Of these, 169 met the c r i t e r i o n of  " s c r e e n i n g p o s i t i v e " and 7841 were " s c r e e n i n g n e g a t i v e " . f o r a s c r e e n i n g p o s i t i v e were d e s c r i b e d i n Chapter called ing.  two.  The c r i t e r i a In c h i l d r e n  " s c r e e n i n g n e g a t i v e " no s i g n of s c o l i o s i s was p r e s e n t on s c r e e n The s i g n s of s c o l i o s i s were l i s t e d  2) Orthopedic  i n Chapter  three.  p o s i t i v e and n e g a t i v e  The r e c o g n i z e d d i a g n o s t i c measure f o r s c o l i o s i s i s the s t a n d i n g a n t e r i o r - p o s t e r i o r thoraco-lumbar  X-ray.  A curve of 11° or more on  X-ray was c o n s i d e r e d an " o r t h o p e d i c p o s i t i v e " or confirmed t h i s study.  I n the case of some r e f e r r a l s the o r t h o p e d i c surgeon  d e f e r r e d X-ray and observed  the c h i l d p e r i o d i c a l l y .  U n t i l these  dren had a d i a g n o s t i c X-ray they were presumed p o s i t i v e . which reached this  scoliosis i n  chil-  Any curve  11° or g r e a t e r was l a b e l l e d a p o s i t i v e f o r the purpose of  study. Those who were not confirmed by a d i a g n o s t i c t e s t or f o l l o w e d  by an o r t h o p e d i s t as a s i g n i f i c a n t  curve were c o n s i d e r e d  negative.  C h i l d r e n who were l a b e l l e d n e g a t i v e were not n e c e s s a r i l y X-rayed but a l l were examined by a p h y s i c i a n who pronounced them as n e g a t i v e . In the study sample t h e r e were two cases where r e f e r r a l was n o t completed and f o u r c h i l d r e n w i t h s p i n a l d i s e a s e o t h e r than scoliosis.  T h i s i s noted  were diagnosed  i n T a b l e V as " o t h e r " .  p r e v i o u s to s c r e e n i n g .  sented were s c o l i o s i s secondary  to:  A l l these  idiopathic children  The o t h e r s p i n a l d i s e a s e s r e p r e Marfan's syndrome, Scheuermann's  76  d i s e a s e , n e u r o l o g i c a l d i s e a s e and p o s t - o p e r a t i v e l y f o l l o w i n g c o r r e c t i o n of pectus  excavatum.  While none of these f o u r cases a r e o r t h o p e d i c  p o s i t i v e s as d e f i n e d they, do i l l u s t r a t e t h a t s c r e e n i n g f o r s c o l i o s i s may  i d e n t i f y other s p i n a l  D e s c r i p t i o n of o r t h o p e d i c The  pathology.  positives  o r t h o p e d i c p o s i t i v e s a r e a v e r y s i g n i f i c a n t group and w i l l  be d e s c r i b e d i n terms of sex, degree of c u r v a t u r e and p r o g r e s s i o n of curves. Sex d i s t r i b u t i o n of the o r t h o p e d i c p o s i t i v e s i s p r e s e n t e d i n Table VI.  Of the t o t a l of 40 (N = 169) who were c a t e g o r i z e d as p o s i -  t i v e , 4 were male (10 percent) and 36 were female (90 p e r c e n t ) , f o r a r a t i o male to female of 1:9.  TABLE VI SEX OF ORTHOPEDICALLY POSITIVE CASES  male  female  year  number  1976-77  17  2  15  14  2  12  1978-79  5  -  5  1979-80  4  -  4  40  4  36  1977-78  Total  •  The degree of c u r v a t u r e on i n i t i a l X-ray examination 10°  to 38°.  ranged from  The two 10° curves were i n c l u d e d i n the o r t h o p e d i c  group because they subsequently  progressed  so t h a t they met the  positive  77  q u a l i f i c a t i o n s of o r t h o p e d i c p o s i t i v e  (see page n i n e ) .  One  child  had  not been X-rayed but i s examined every s i x months by an o r t h o p e d i c surgeon who immature.  has c a t e g o r i z e d her as c l i n i c a l l y p o s i t i v e and  skeletally  For these reasons she too q u a l i f i e s as o r t h o p e d i c p o s i t i v e .  Of the 38 c u r v e s , 25 (65.8 p e r c e n t ) are between 10° and 19°, 10 p e r c e n t ) l i e between 20° and 30°.  One  (26.3  29° and 3 (7.9 p e r c e n t ) a r e g r e a t e r than  curve has not been X-rayed  and  the X-ray s t a t u s of a g i r l i n  b r a c e treatment i n C a l i f o r n i a i s not known. P r o g r e s s i o n of curves i s r e v e a l e d by p e r i o d i c X-ray  examinations.  Of those curves (36 of 38) which have been f o l l o w e d r a d i o g r a p h i c a l l y , 13  (36.1 p e r c e n t ) showed p r o g r e s s i o n r a n g i n g between 1° and 20°, 16  (44.4  p e r c e n t ) remained unchanged and 7 (19.4 p e r c e n t ) decreased from 1° to 6°.  None of the 25 curves which were below 20° i n i t i a l l y  treatment.  has  required  Of the 13 curves g r e a t e r than 20°, 8 have r e c e i v e d  treatment by b r a c i n g or s u r g e r y .  active  Of the 25 curves below 20°, 5 or  20  p e r c e n t p r o g r e s s e d whereas i n the 13 curves over 20°, 80 p e r c e n t of those f o l l o w e d by X-ray i n c r e a s e d (8 of 10), two were operated immediately and  one r e f u s e d f o l l o w - u p .  i n males none p r o g r e s s e d .  on  Of the four curves o c c u r r i n g  Figure 4 i l l u s t r a t e s  the p a t t e r n of c u r v a -  t u r e s i n the sample.  3) True p r e v a l e n c e As d i s c u s s e d i n c h a p t e r t h r e e the f i g u r e f o r t r u e p r e v a l e n c e i s n e c e s s a r y to complete the f o u r f o l d  t a b l e and determine measures of  v a l i d i t y such as s e n s i t i v i t y , s p e c i f i c i t y and p r e d i c t i v e v a l u e . The number of t o t a l d i s e a s e d i n the p o p u l a t i o n i d e a l l y would  be  7°  /0°  15°  20°  2 5 ° 30° JS° - V O " V 5 °  50°  INITIAL CURVE F i g . 4 . — P a t t e r n o f p r o g r e s s of s c o l i o s i s curves from curve to maximum curve.  initia  determined by r a d i o g r a p h y  however i t i s u n e t h i c a l to submit  individuals  to t h i s procedure f o r r e s e a r c h purposes as w e l l as c o s t l y and a b l e to the p o p u l a t i o n .  Other s t r a t e g i e s  as suggested  unaccept-  by Grant  (1974)  are a v a i l a b l e .  For the purpose-of e s t i m a t i o n of p r e v a l e n c e of  adoles-  cent i d i o p a t h i c  s c o l i o s i s the s t u d i e s of Rogala e t a l . (1978), Brooks  (1980) and Kane (1977b) were used to s e l e c t a p r e v a l e n c e  of 2 p e r c e n t .  In a s c r e e n i n g p o p u l a t i o n of 8010  cases of s c o l -  t h i s would suggest  160  i o s i s w i t h an 11° c u r v a t u r e or g r e a t e r .  The  fourfold  table  T a b l e V I I shows the f i g u r e s p o s i t i v e and  f o r diseased p o s i t i v e ,  t o t a l p o s i t i v e from the s c r e e n i n g program r e s u l t s .  adjustment to the d i s e a s e d p o s i t i v e group was c h i l d r e n who  non-diseased  were screened  An  made to account f o r  two  and were o t h o p e d i c a l l y p o s i t i v e but were  a l r e a d y known and under p h y s i c i a n o b s e r v a t i o n .  These two  are  screening  p o s i t i v e because t h e i r curves have been a c c u r a t e l y i d e n t i f i e d by  the  s c r e e n i n g program.  ,  TABLE V I I  FOURFOLD TABLE DERIVED USING PREVALENCE STATISTICS  Diagnosis Screening  results  diseased  non-diseased  total  127  169  Positive  42  Negative  118  7723  7841  Total  160*  7850  8010  *The 2 p e r c e n t p r e v a l e n c e s t a t i s t i c (Rogala e t a l . 1978) the s c r e e n i n g p o p u l a t i o n , i . e . 8010 X .02 = 160. C h i Square w i t h 1° of freedom = 69.8019 p<.01.  i s a p p l i e d to  By u s i n g the 2 p e r c e n t p r e v a l e n c e  c a l c u l a t i o n to e s t i m a t e  t o t a l d i s e a s e d p o p u l a t i o n as 160,  a diseased screening negative  of 118  f o r non-diseased  and  can be d e r i v e d .  t o t a l non-diseased  Estimates  screening  a  group  negative  then f o l l o w by a d d i t i o n or s u b t r a c t i o n (see  Chapter t h r e e , F i g . : 3, page 65) . From the d e r i v e d f o u r f o l d made about the s c r e e n i n g t e s t  t a b l e c e r t a i n e s t i m a t i o n s can now  be  (see formulae page 66).  Sensitivity Overall  sensitivity -r|| ±ou  X  100  =  26.2%  For each of the y e a r s of the s c r e e n i n g program s e n s i t i v i t y calculated  as:  1976-77  3^-  X  100  =  32.7%  •Jy  X  100  =  37.8%  Tr 34  X  100  =  14.7%  ~  X  100  =  10.8%  X  100  =  98.4%  1977-78  1978-79  1979-80  Specificity 7721 J  7850  was  Overreferral  (false  positives) 127  169 Underreferral  (false  X  100 = 75.1%  X  100 = 1.5%  X  100 = 24.9%  negatives) 118 7841  P o s i t i v e predictive value 42  169 O v e r a l l p r e d i c t i v e value 42  + 7723 8010  X 100 = 96.9%  P r e v a l e n c e of s c o l i o s i s a t SFHD Comparison of the p r e v a l e n c e r a t e of s c o l i o s i s curves  identified  at SFHD w i t h o t h e r s i n the l i t e r a t u r e p r o v i d e s another measure of the v a l i d i t y of the s c r e e n i n g t e s t .  P r e v a l e n c e w i l l be d i s c u s s e d as p r e -  v a l e n c e of curves 11° and g r e a t e r and p r e v a l e n c e of t r e a t a b l e  curves.  P r e v a l e n c e of curves 11° and g r e a t e r was used t o e s t i m a t e the p r e v a l e n c e of s c o l i o s i s i n the p o p u l a t i o n of SFHD screened between September 1976 and June 1980. orthopedically positive, g r a p h i c examination  The number of c h i l d r e n i d e n t i f i e d as  t h a t i s w i t h a curve 11° o r g r e a t e r on r a d i o -  (Cobb method o f c a l c u l a t i o n )  (N = 40) a l o n g w i t h  the t o t a l s c r e e n i n g p o p u l a t i o n of 8010 i s the b a s i s of the c a l c u l a t i o n but  two adjustments were made t o r e f l e c t a more a c c u r a t e p r e v a l e n c e  figure. that  The 9 c h i l d r e n who were not screened because p a r e n t s a d v i s e d  they were under management  as p o s i t i v e  f o r s p i n a l d i s e a s e w i l l be c o n s i d e r e d  ( a l t h o u g h the t r u e s t a t u s of a l l cases i n terms o f b e i n g  82  o r t h o p e d i c p o s i t i v e i s not known) a l o n g w i t h the 2 c h i l d r e n who were s c r e e n i n g p o s i t i v e and a l r e a d y known t o t h e i r p h y s i c i a n s as s c o l i o t i c s , f o r a t o t a l of 51 cases. The c a l c u l a t i o n f o r p r e v a l e n c e then i s X  100 = 0.636% or rounded t o 0.6%  The r a t e i s expressed as a percentage the l i t e r a t u r e . adjustment  o r p e r hundred to concur w i t h  The p r e v a l e n c e r a t e f o r each s c r e e n i n g y e a r w i t h  f o r other s c o l i o t i c s  i s given i n Table V I I I .  TABLE V I I I NUMBER AND RATE OF ORTHOPEDIC POSITIVES PER SCREENING YEAR  number screened  year  orthopedic  positive  other  % of t o t a l  1976-77  2587  17  0  0.66  1977-78  1873  14  5  1.0  1978-79  1690  5  3  0.47  1979-80  1860  4  3  0.38  Total  8010  40  11  0.636  I n c i d e n t a l l y the p r e v a l e n c e r a t e was r e p o r t e d as 0.65 p e r c e n t f o r the SFHD p i l o t p r o j e c t January  t o June 1976 (SFHD Report  1977).  The p r e v a l e n c e of t r e a t a b l e curves i n the s c r e e n i n g p o p u l a t i o n i s suggested  i n the l i t e r a t u r e  or 0.275 p e r hundred.  (Rogala e t a l . 1978) as 2.75 per thousand  A t SFHD t h e r e have been 12 cases i n which a c t i v e  treatment was recommended  ( b r a c i n g and/or s u r g e r y ) .  who r e j e c t e d a c t i v e treatment.  T h i s i n c l u d e s those  The r a t e a t SFHD f o r t r e a t a b l e curves i s  83  0.1498 per hundred or about o n e - h a l f the r a t e found Rogala et a l . (1978). the 11 presumptive  T h i s p r e v a l e n c e f i g u r e does not take i n t o  I f they were a l l a c t i v e l y t r e a t e d the p r e v a l e n c e  t r e a t a b l e curves would  1  2  be  ontn  1  1  x  which i s c l o s e to t h a t of Rogala r e p o r t e d by Moe  account  cases i n the community t h a t were added f o r c a l c u l a -  t i o n of p r e v a l e n c e . of  i n the study of  e t a l . (1978).  gery f o r s c o l i o s i s and  1  0  0  = 0.287%  e t a l . (1978) and  the 0.3  percent  I t i s known t h a t 2 of the 11 had  sur-  t h a t 2 a r e under p h y s i c i a n o b s e r v a t i o n b u t  the  s t a t u s of the other 7 i s unknown.  Availability  of Resources  The r e s o u r c e s d e s c r i b e d are those which are u t i l i z e d s c r e e n i n g program and The  i n the  those which a r e r e q u i r e d as a r e s u l t of s c r e e n i n g .  a c c e s s i b i l i t y of s e r v i c e s f o r f o l l o w - u p of the s c r e e n i n g r e f e r r a l s  w i l l be r e p o r t e d and p a r t i c u l a r mention made of the o r t h o p e d i c s e r v i c e s .  S c r e e n i n g program r e s o u r c e s The d a t a i n T a b l e IX are from the annual r e p o r t s w r i t t e n by p h y s i o t h e r a p i s t s a t SFHD. ing  year.  No  f i g u r e s were e s t i m a t e d i n 1978-79 s c r e e n -  To complete the t a b l e t h e r e f o r e an e s t i m a t e of r e s o u r c e s  i n t h a t year i s made.  The c o s t per screenee  1979-80 i t was  I f each of these c o s t s i s m u l t i p l i e d by  number screened  $2.19.  the  i n 1977-78 was  i n 1978-79 (1690) and averaged,  used  $2.07, i n the  the f i g u r e of $3599.70  c o u l d be c o n s i d e r e d an estimate f o r 1978-79 s c r e e n i n g c o s t s .  Given  t h a t a l l hours of s e r v i c e a r e e s t i m a t e d t h e r e i s not a p r e c i s e c o s t i n g  TABLE IX SFHD RESOURCES UTILIZED IN SCOLIOSIS SCREENING  number screened  1976-77  1977-78  1979-80  T o t a l Cost  2587  1873  1860  8010*  time i n hours physiotherapy  400 ($8.5/h) $3,400.00  137 ($10/h) $1,370.00  107 ($12.8/h) $1,369.60  644 $6,139.60  public health nursing  127 ($10/h) $1,270.00  146 ($10/h) $1,460.00  221 ( $ l l / h ) $2,431.00  494 $5,161.00  clerical  32 ($6.8/h) $217.60  34 ($6.8/h) $231.20  p r e p a r a t i o n of r e p o r t  100 ($8.5/h) $850.00  55 ($10/h) $550.00  e v a l u a t i o n study  28 ($10.7/h) $299.60  25 ( $ l l / h ) $275.00  medical h e a l t h o f f i c e r  10 $200.00  total  hours  t o t a l cost  29 ($7.3/h) $211.70 5 ($12.8/h) $64.00  95 $660.50 160 $1,464.00 53 $5,746 10 $200.00  697  397  362  1456  $6,237.20  $3,886.20  $4,076.30  $14,199.70  I f e s t i m a t e of $3,599.70 i s used f o r 1978-79 t o t a l c o s t = $17,799 .40. * i n c l u d e s 1690 screened 1978-79.  85  f o r any y e a r .  In round  has been $17,800.  f i g u r e s f o r f o u r y e a r s the c o s t of s c r e e n i n g  Costs i n c l u d e s a l a r i e s of h e a l t h d i s t r i c t  personnel  i n v o l v e d i n the program but excludes t r a v e l expenses, h e a l t h d i s t r i c t o f f i c e overhead, and  c l e r i c a l s e r v i c e i n the s c h o o l s , s t a t i o n e r y and  c o s t of s u p p l i e s such as t r a i n i n g manuals, t e x t s and  postage  films.  Cost of o t h e r s e r v i c e s u t i l i z e d The number of s e r v i c e s i n the c a t e g o r i e s of X-ray,  f a m i l y phy-  s i c i a n , o r t h o p e d i c s p e c i a l i s t , c h i r o p r a c t o r , p h y s i o t h e r a p y and b r a c i n g i s p r e s e n t e d f o r the o r t h o p e d i c p o s i t i v e cases i n T a b l e X.  Although  s i x of these c h i l d r e n r e q u i r e d s u r g e r y , t h i s item i s not i n c l u d e d as it  i s the w r i t e r ' s c o n t e n t i o n t h a t s u r g e r y would have o c c u r r e d e v e n t u a l l y  without  s c r e e n i n g , when the curve was  noted by the f a m i l y or p h y s i c i a n  and m e d i c a l c a r e commenced. The number of r e f e r r a l s seen by the o r t h o p e d i s t and 169  c h i l d r e n who  s i c i a n who dren  the X-ray  the g e n e r a l p r a c t i t i o n e r  s t a t u s i s found  i n T a b l e XI.  Of  and  those  were s c r e e n i n g p o s i t i v e , 166 went to the f a m i l y phy-  ordered X-rays  f o r 39 p e r c e n t of them.  Thirty-eight  chil-  (24 p e r c e n t ) were pronounced normal on c l i n i c a l examination  w i t h o u t X-ray.  Some were not X-rayed  by the g e n e r a l p r a c t i t i o n e r  r e f e r r e d d i r e c t l y t o the o r t h o p e d i c s p e c i a l i s t who of the c h i l d r e n seen by  X-rayed  alone but  74 p e r c e n t  him.  The c o s t of h e a l t h care s e r v i c e s which have been u t i l i z e d f o r the s c r e e n i n g p o s i t i v e s of the program f o r the f o u r y e a r s of the are tabulated i n Table XII.  The h i g h e s t c o s t of any  o c c u r r e d i n 1976-77, b r a c i n g was  the most expensive  study  s c r e e n i n g year s e r v i c e f o l l o w e d by  TABLE X NUMBER OF SERVICES PROVIDED FOR ORTHOPEDIC POSITIVES  1976-77  1977-78  1978-79  1979-80  total  Number of cases  17  -  5  4  40  Number o f X-rays  48  35  11  7  98  21  16  6  5  46  V i s i t s to orthopedic specialist  80  49  19  13  158  Number of c h i r o p r a c t i c services  39  -  22  -  61  169  34  14  4  221  Number o f cases braced  1  2  2  1  6  Surgical  3  -  3  -  6  Visits  to family  physician  Number o f p h y s i o t h e r a p y services  procedures  oo  ( N  TABLE XI NUMBER OF REFERRALS SEEN BY GENERAL PRACTITIONER AND ORTHOPEDIST AND X-RAY STATUS  Year  Number Referred  To General Practitioner  1976-77  84  83  36  43%  44  34  77%  1977-78  42  41  17  41%  24  19  79%  1978-79  17  17  5  29%  12  7  58%  1979-80  26  25  6  24%  9  6'  67%  169  166  64  39%  89  Total  Refused r e f e r r a l 2, Unknown 1.  X-ray  Percentage  To Orthopedist  X-ray  66  Percentage  74%  TABLE X I I COST OF SERVICES* PROVIDED FOR ORTHOPEDIC POSITIVE SCREENEES (in dollars)  1976-77  Number o f cases  1977-78  14**  17  1978-79  5  1979-80  Total  4  39  X-rays  795.60  647.40  204.80  148.10  1,795.90  Family p h y s i c i a n  206.30  165.75  68.35  60.50  500.90  1,351.75  1,006.68  412.30  317.30  3,088.03  181.25  -  Orthopedic  specialist  Chiropractic  -  319.25  500.50  Physiotherapy  1,188.50  240.75  100.00  28.00  1,557.25  Bracing  1,600.00  900.00  1,300.00  1,000.00  4,800.00  Total  5,461.40  2,960.58  2,266.70  1,553.90  12,242.58  *Surgery not i n c l u d e d as a c o s t of s c r e e n i n g . **Costs a r e unknown f o r one case  (braced).  the c o s t o f the o r t h o p e d i c a t $12,242.58, e x c l u d i n g The  specialist.  The t o t a l c o s t was e s t i m a t e d  c o s t s o f surgery  c o s t of s c r e e n i n g  must a l s o i n c l u d e t h e c o s t s t o t h e h e a l t h  c a r e system o f those who were s c r e e n i n g nosed as n e g a t i v e .  p o s i t i v e but u l t i m a t e l y  diag-  The number o f s e r v i c e s f o r t h i s group i s p r e s e n t e d  i n T a b l e X I I I and the c o s t s i n T a b l e XIV. at $6,324.63.  and h o s p i t a l i z a t i o n .  The t o t a l c o s t i s estimated  The most c o s t l y s e r v i c e f o r t h e f a l s e p o s i t i v e s , which  t h i s group c o n s t i t u t e s , was f o r t h e o r t h o p e d i c  A c c e p t a b i l i t y of f o l l o w - u p  specialist.  services  None o f t h e f a m i l i e s expressed any d i f f i c u l t i e s i n o b t a i n i n g appointments w i t h p h y s i c i a n s , e i t h e r f a m i l y d o c t o r s  or o r t h o p e d i s t s .  When an e a r l i e r r e v i e w of the s c o l i o s i s program was done there were comments t h a t the w a i t f o r o r t h o p e d i c t h i s was n o t mentioned d u r i n g  appointments was unduly l o n g b u t  any o f t h e l a t e s t  telephone  interviews.  X-ray s e r v i c e s , p h y s i o t h e r a p y and c h i r o p r a c t i c s e r v i c e s were n o t ment i o n e d as c a u s i n g The  any problem i n a v a i l a b i l i t y .  o r t h o t i c s e r v i c e has been an area of concern to those who  required bracing during of t h i s s c r e e n i n g Hospital.  the p e r i o d of t h i s study.  program t h e s e r v i c e was p r o v i d e d  A t an e a r l y stage a t Shaughnessy  There was an i n t e r v a l o f over a y e a r when t h i s o r t h o t i s t :  from Shaughnessy who i s r e c o g n i z e d Milwaukee b r a c e was away.  as the p r o v i n c i a l expert  on t h e  On h i s r e t u r n o r t h o t i c s e r v i c e resumed  through h i s p r i v a t e f i r m and h i s s e r v i c e s a r e a v a i l a b l e a t the weekly C h i l d r e n ' s H o s p i t a l s c o l i o s i s c l i n i c where t h e o r t h o t i s t i s p a r t of the team e v a l u a t i n g and p r e s c r i b i n g b r a c e treatment.  TABLE X I I I SERVICES PROVIDED FOR ORTHOPEDIC NEGATIVE* SCREENEES  '1976-77  '1977-78  S c r e e n i n g Year " 1978-79  i  -1979-80  Total  T o t a l Cases  65  27  9  20  121  X-rays  47  18  7  8  80  118  48  18  27  211  V i s i t s to orthopedic specialist  47  24  6  5  82  Chiropractic services  19  0  0  0  19  Physiotherapy v i s i t s  17  28  0  0  45  V i s i t s to family physician  *does not i n c l u d e other s p i n a l d i s e a s e s .  o  - TABLE XIV COST OF SERVICES FOR ORTHOPEDIC NEGATIVE SCREENEES (in dollars)  1976-77 Number of cases  65  1977-78 27  1978-79 9  1979-80 20  Total 121  749.90  328.90  90.90  156.20  1,325.90  Family p h y s i c i a n  1,187.40  503.20  204.20  340.40  2,235.20  Orthopedic  1,280.87  660.82  157.14  196.40  2,295.23  X-rays  specialist  Chiropractic  150.55  -  -  -  150.55  Phys i o t h e r a p y  121.75  196.00  -  -  317.75  3,490.47  1,688.92  Total  452.24  693.00  6,324.63  92  Those c h i l d r e n from SFHD who clinic tic  at C h i l d r e n ' s H o s p i t a l had  treatment.  o r t h o t i s t and ment.  The  were not r e f e r r e d to the  a l e s s c o o r d i n a t e d approach to o r t h o -  team of p h y s i o t h e r a p i s t , o r t h o p e d i c  c h i l d / p a r e n t was  scoliosis  specialist,  not i n v o l v e d i n p r e s c r i p t i o n and  Of the s i x c h i l d r e n who  were braced  t h r e e had  problems w i t h  adjustment to the b r a c e or i n o b t a i n i n g a good c o r r e c t i o n of curves.  Of the t h r e e s u c c e s s f u l l y braced  assesstheir  their  one has been f o l l o w e d  every  t h r e e months a t the C h i l d r e n ' s H o s p i t a l c l i n i c w h i l e the second  child  i s seen p r i v a t e l y w i t h review by the o r t h o p e d i s t every months w i t h r e f i t t i n g of the b r a c e as i n d i c a t e d . o r t h o t i c s e r v i c e r e c e i v e d by  t h r e e to f o u r  The d e t a i l s of  the case l i v i n g out of B r i t i s h  the  Columbia  i s not known.  Orthopedic  services i n B r i t i s h  Columbia  In the l a t e s t D i r e c t o r y p u b l i s h e d by and  Surgeons of B.C.  Of the 108,  (1980) t h e r e a r e 108  o r t h o p e d i c surgeons  80 or 74 p e r c e n t are l o c a t e d i n the Lower Mainland  Greater V i c t o r i a region. ists  the C o l l e g e of P h y s i c i a n s  i s 1,372,002.  The  p o p u l a t i o n covered by  The b a l a n c e of the people  l o c a t e d i n areas s e r v e d by the 28 remaining  these 80  i n B.C.,  and orthoped-  1,264,898, are  orthopedic  They a r e l o c a t e d as f o l l o w s : Vancouver I s l a n d (except V i c t o r i a ) Okanogan (Vernon, Kelowna, P e n t i c t o n ) Fraser Valley Trail Nelson Kamloops P r i n c e George Dawson Creek Kitimat  listed.  7 7 5 1 1 3 2 1 1  specialists.  93  P o p u l a t i o n i n f o r m a t i o n was p r o v i d e d by H o s p i t a l Ministry of Health, V i c t o r i a  (Selwood  Programs,  1981).  Surgery f o r s c o l i o s i s was performed on 84 people i n B.C. d u r i n g the p e r i o d A p r i l 1, 1979 t o March 31, 1980.  The f o l l o w i n g T a b l e XV  i n d i c a t e s by h o s p i t a l where surgeons performed s u r g e r y w i t h t h e H a r r i n g t o n Rod and s p i n a l f u s i o n (ICD code 930.4).  Of the 84 o p e r a -  t i o n s , 82 (98 p e r c e n t ) were performed i n h o s p i t a l s i n t h e v i c i n i t y of Vancouver  and V i c t o r i a .  TABLE XV SURGERY WITH HARRINGTON ROD (ICN CODE 930.4) IN B.C. BY HOSPITAL APRIL 1, 1981 TO MARCH 31, 1980  Total  Hospital  0-14  15-44  45-69  70-  32  22  10  -  -  Royal Columbian (New Westminster)  7  2  4  1  Royal I n l a n d (Kamloops)  2  —  —  2  Royal J u b i l e e (Victoria)  4  2  2  Shaughnessy (Vancouver)  16  2  14  — — — —  Children's (Vancouver)  S u r r e y Memorial (Surrey) Vancouver G e n e r a l (Vancouver) V i c t o r i a General (Victoria) Total SOURCE:  3  —  19  9  1  1  84  38  —  —  3 10  — 43  — — 3  — —  W. E. Selwood, Research D i v i s i o n , H o s p i t a l Programs, M i n i s t r y of H e a l t h , V i c t o r i a , B.C. I n t e r v i e w , June 23, 1981.  94  CHAPTER V  DISCUSSION  In t h i s study e v a l u a t i o n of s c o l i o s i s s c r e e n i n g at SFHD i s based on the  the  application  of e s t a b l i s h e d c r i t e r i a to the program r e s u l t s  evidence i n the  i d e n t i f i e d i n the  l i t e r a t u r e about s c o l i o s i s .  l i t e r a t u r e review w i l l be  c r i t e r i a were chosen as of s p e c i a l available  and  the  These f o u r c r i t e r i a acceptability  of the  2)  acceptability  of  4)  the  c r i t e r i a t h e r e w i l l be  The  f o r the  resources for t h i s  data  study.  screening  test  r e s u l t s o f t h i s study to these p r i n c i p a l  a b r i e f d i s c u s s i o n of e v a l u a t i o n of  the  significance  of  the  t h i s s c o l i o s i s s c r e e n i n g program.  of General C r i t e r i a  a h e a l t h problem  c r i t e r i o n t h a t s c o l i o s i s must be  j u s t i f y s c r e e n i n g has t a l i t y due  the b a s i s of  treatment  Application Importance as  principal  resources  the  remaining c r i t e r i a to the  criteria  test  a v a i l a b i l i t y of  Before r e l a t i n g  on  four  not  on  are:  1)  3) v a l i d i t y of  used but  significance  l i m i t s of time and  A l l twelve  and  been f u l f i l l e d .  to s c o l i o s i s i n the  an  important d i s e a s e  Data on m o r b i d i t y and  population i s limited.  The  seven y e a r s from 1972-78 r e v e a l e d 2 deaths i n B.C.  to mor-  statistics and  24  in  Canada due to s c o l i o s i s , an i n s i g n i f i c a n t number. tistics  Valid morbidity s t a -  a r e not a v a i l a b l e but t h e r e a r e some r e p o r t s i n the l i t e r a t u r e  which d i s c u s s d i s a b i l i t y and death due t o s c o l i o s i s . p a i n , dyspnea and premature death range  Reports o f back  from normal ( C o l l i s and P o n s e t i  1968) t o n o t a b l y h i g h e r ( N i l s o n n e and Lungren 1968) i n u n t r e a t e d iosis patients.  scol-  In the sphere o f s o c i a l e f f e c t mention i s made o f fewer  m a r r i a g e s , embarrassment about appearance and s o c i a l i s o l a t i o n among scoliotics.  I n f o r m a t i o n r e g a r d i n g the degree  of c u r v a t u r e , type o f  s c o l i o s i s and p r e v a l e n c e of the d i s a b i l i t y a r e a l l n e c e s s a r y t o e v a l uate the r e p o r t e d e f f e c t s o f s c o l i o s i s and a r e not always a v a i l a b l e to a s s i s t i n r e a c h i n g a c o n c l u s i o n about  Accepted  (Effective)  the s i g n i f i c a n c e o f the d i s e a s e .  treatment  The l i t e r a t u r e survey found t h a t the e f f i c a c y o f treatment f o r s c o l i o s i s has n o t been a s s e s s e d by e i t h e r randomized a t r i a l of quasi-experimental design. treatment  clinical  t r i a l or  The d e s c r i p t i v e evidence  from t h i s study i s n o t c o n c l u s i v e .  about  In the study sample s i x  c h i l d r e n were b r a c e d ; treatment was u n s u c c e s s f u l i n t h r e e cases and i t would be premature t o c a l l of  s u r g e r y i n the s i x cases has appeared  girl of  the t h r e e remaining cases s u c c e s s f u l .  t o be s u c c e s s f u l , a l t h o u g h one  r e q u i r e s a second o p e r a t i o n t o modify  discomfort.  the H a r r i n g t o n Rod because  T h i s i s r e p o r t e d to be a minor  T h i s study has not attempted  Outcome  procedure.  t o e v a l u a t e the e f f i c a c y o f p h y s i o -  therapy treatment but i n view o f the r e p o r t e d l a c k o f e f f i c a c y o f exerc i s e as a treatment treatment  f o r s c o l i o s i s the use of p h y s i o t h e r a p y as s o l e  i n t e n cases was a q u e s t i o n a b l e p r a c t i c e .  96 A c c e p t a b i l i t y o f treatment which was c o n s i d e r e d a l o n g w i t h e f f i c a c y as a component of the e f f e c t i v e n e s s o f treatment w i l l be cons i d e r e d as one o f the f o u r p r i n c i p a l  Recognized  criteria.  l a t e n t stage and known n a t u r a l h i s t o r y  From what i s w r i t t e n about  s c o l i o s i s t h e r e may be a r e c o g n i z a b l e  l a t e n t o r e a r l y symptomatic stage b u t i t i s not y e t c l e a r which curves w i l l p r o g r e s s from t h i s s t a g e . now p o s s i b l e because  There i s promise  o f widespread  that e v a l u a t i v e  studies  screening i n e a r l y adolescence  will  shed l i g h t on the n a t u r a l h i s t o r y o f s c o l i o s i s i n c l u d i n g the l a t e n t period.  The evidence t o date from p r o s p e c t i v e s t u d i e s suggests  some curves improve,  many remain unchanged and about  p r o g r e s s t o what i s c a l l e d a t r e a t a b l e c u r v e . of  that  t h r e e p e r thousand  I n t h i s study sample none  the curves (N = 25) which were below 20° i n i t i a l l y p r o g r e s s e d t o a  t r e a t a b l e curve.  In those i n i t i a l l y  20° and above (N = 13), 77 p e r c e n t  (N = 10) p r o g r e s s e d or r e q u i r e d immediate treatment. by X-ray  (N = 10) i n the 20° and over group  Of those f o l l o w e d  80 p e r c e n t p r o g r e s s e d com-  pared to 20 p e r c e n t i n the under 20° c a t e g o r y (5 o f 24). These f i n d i n g s c o u l d have i m p l i c a t i o n s f o r m o d i f y i n g the s c r e e n i n g t e s t so t h a t i n s i g n i f i c a n t curves  fewer  ( i . e . below 20°) a r e r e f e r r e d .  Whom to t r e a t as a p a t i e n t The i s s u e o f who to t r e a t as a s c o l i o s i s p a t i e n t may be somewhat confusing u n t i l  the upper range of c u r v a t u r e s i s reached.  There i s  g e n e r a l agreement t h a t curves over 50° r e q u i r e s u r g e r y , those between 40° t o 50° a r e d e b a t a b l e , and that f o r curves between 30° and 40° b r a c i n g i s the most d e s i r a b l e treatment f o r the m a j o r i t y o f cases.  Curves  between 20° and 30° a r e u s u a l l y c o s m e t i c a l l y a c c e p t a b l e and Rogala e t al.  (1978) found t h a t one i n f i v e i n t h i s range i n an immature  d i d not p r o g r e s s so t h a t b r a c i n g should not be a p p l i e d I n s t e a d i t was  female  routinely.  suggested w a i t i n g f o r s i g n s t h a t the c u r v e was. p r o g r e s -  sing before bracing. Kane (1977b) has d e f i n e d the p o p u l a t i o n at r i s k f o r s c o l i o s i s as those w i t h curves 11° and o v e r .  T a y l o r e t a l . (1978a) suggests  there i s no sound agreement f o r management of curves under 25° Howell and C r a i g fying.  (1980) suggest 15° curves are the ones t o aim a t  T h i s s c r e e n i n g program u s i n g 11° and over as the l e v e l o f  f i c a n c e had a p o s i t i v e p r e d i c t i v e power of about one out o f f o u r p o s i t i v e s was if  and  a curve was  truly positive.  signi-  25 p e r c e n t , which means  The q u e s t i o n o c c u r s t h a t  c o n s i d e r e d s i g n i f i c a n t o n l y i f i t was  s c r e e n i n g procedure was  identi-  20° or over and  the  geared to d e t e c t i o n of t h a t range of c u r v a t u r e ,  would a b e t t e r program r e s u l t ? Bone age appears  to be the c r i t i c a l  factor.  U n l e s s the  d u a l has growth p o t e n t i a l b r a c i n g w i l l not be e f f e c t i v e . not be r e l i e d on to c o r r e c t a curve but i t may  indivi-  B r a c i n g can  a r r e s t the p r o g r e s s of  a curve d u r i n g the b a l a n c e of the growth p e r i o d .  I f bone age i s t h i s  important f o r p r o p e r curve management, l a c k o f an X-ray would appear be a major d e f i c i t  i n d i a g n o s i s and treatment of s c o l i o s i s .  s c r e e n i n g p o s i t i v e s i n t h i s study 38 The presumption  i s t h a t t h e r e was  Of  to  the  (24 p e r c e n t ) d i d not r e c e i v e X - r a y s .  l a c k of c l i n i c a l evidence of s c o l i o s i s  upon examination by the p h y s i c i a n to warrant  exposure  to r a d i a t i o n .  i s a l s o presumed t h a t these p o t e n t i a l p o s i t i v e s were examined by c i a n s c o g n i z a n t of the e a r l y c l i n i c a l  s i g n s of s c o l i o s i s : .  No  It  physi-  further  98  rechecks were done by t h e h e a l t h d i s t r i c t  s c r e e n i n g team f o l l o w i n g the  p h y s i c i a n ' s r e p o r t of n e g a t i v e f i n d i n g s unsupported by X-ray.  Economic  balance The  c r i t e r i a s u g g e s t i n g economic b a l a n c e i n the c o s t o f c a s e -  f i n d i n g i n r e l a t i o n to t o t a l medical expenditures the l i t e r a t u r e o r i n t h i s study.  i s n o t answered i n  While there has been some e f f o r t t o  e s t i m a t e d i r e c t c o s t s , i n d i r e c t c o s t s f o r a n x i e t y , time l o s t and f o r h e a l t h d i s t r i c t overhead c o s t s ( f o r example, telephone, and books, postage) a r e not e s t i m a t e d .  office,  films  There i s the o p p o r t u n i t y to  examine the m e d i c a l e x p e n d i t u r e s which have r e s u l t e d from the s c r e e n i n g program i n terms o f the f o l l o w - u p o f b o t h o r t h o p e d i c p o s i t i v e and negative  screenees. T o t a l estimated  c o s t s o f $18,567.21 (Table X I I and XIV) should  be c o n s i d e r e d as a minimal f i g u r e which does n o t i n c l u d e the c o s t o f the s i x s u r g i c a l procedures program.  which r e s u l t e d from the r e f e r r a l s o f the  I t i s c o n s i d e r e d t h a t these o p e r a t i o n s would have o c c u r r e d  r e g a r d l e s s o f the s c r e e n i n g program.  They have o c c u r r e d e a r l i e r and  w i t h presumably b e t t e r r e s u l t s , a b e n e f i t which has n o t been measured at t h i s time.  Costs f o r one of the b r a c e d  c h i l d r e n t r e a t e d i n the U.S.A.  were n o t e s t i m a t e d . An i n t e r e s t i n g a s p e c t o f c o s t i s t h a t many c h i l d r e n pronounced as n e g a t i v e c o n t i n u e t o be f o l l o w e d .  I n a North Vancouver study  (1981)  of 111 c h i l d r e n p h y s i c i a n s c a t e g o r i z e d as normal i t was r e p o r t e d t h a t 39 would c o n t i n u e to be f o l l o w e d by the p r i v a t e p h y s i c i a n . of c o n t i n u e d  The c o s t  s u r v e i l l a n c e should be e v a l u a t e d i n terms, of e v e n t u a l  returns.  An  i n i t i a l d i a g n o s t i c X-ray as recommended a t SFHD should  mean t h a t o n l y  Continuous  those curves "at r i s k " f o r p r o g r e s s i o n  are  followed.  case-finding  The  c r i t e r i a t h a t c a s e - f i n d i n g should  be  continuous throughout  an i n d i v i d u a l ' s p e r i o d of " r i s k " i s more a p p l i c a b l e to other screening  than to s c o l i o s i s .  e r a l l y acceptable a c t i v e and  to s c r e e n  In the case of s c o l i o s i s  i t appears gen-  at a s t a g e of a d o l e s c e n c e when growth i s  e a r l y s c o l i o t i c curves are v i s i b l e .  Ages of 12  to 14 have been c o n s i d e r e d  most s u i t a b l e .  (1978) study i n v o l v i n g a sample t e s t e d at an e a r l i e r age efit.  From the l i t e r a t u r e  once d u r i n g  the age  i t would appear t h a t s c r e e n i n g  represented  to c o n t i n u i t y of a s c r e e n i n g for  five  The  and  every In  ben-  child respect  a continuous program  cost-effectiveness  c r i t e r i a c a l l i n g f o r knowledge of c o s t - b e n e f i t , c o s t -  e f f e c t i v e n e s s have not been met The  e f i t s and  oontain  described  i n the  this  literature  a mechanism f o r weighing c o s t s a g a i n s t  because of the long-term  a n a l y s i s would be  Estimation  i n s t u d i e s i n the l i t e r a t u r e or by  SFHD program l i k e a l l o t h e r s  searched does not  ben-  n a t u r e of the c o n d i t i o n economic  complex.  of s o c i a l  Estimation fic  found no  i n grade seven i s adequate.  program SFHD has had  Rogala's  years.  Cost-benefit  study.  types of  s c r u t i n y i s not  benefits  of s o c i a l b e n e f i t s i n terms t h a t w i t h s t a n d p o s s i b l e from the  literature  scienti-  or t h i s study.  The  100  population  i n the s t u d i e s which d e s c r i b e  are n o t r e p r e s e n t a t i v e  populations  the s o c i a l c o s t s o f s c o l i o s i s  and c o n t r o l groups have n o t been  used.  E v a l u a t i o n by P r i n c i p a l C r i t e r i a A p p l i c a t i o n of the f o u r c r i t e r i a to the r e s u l t s of s c r e e n i n g a t SFHD w i l l now be d i s c u s s e d .  A c c e p t a b i l i t y of s c r e e n i n g  test  At SFHD the s c o l i o s i s program has been v e r y w e l l accepted by parents,  c h i l d r e n screened and p h y s i c i a n s .  t i a l screening tability. t h i s high  (21/8031) of 0.3 percent  i s i n d i c a t i v e of t h i s  l e v e l o f acceptance. do n o t reach home.  i n v e s t i g a t o r i t was v o l u n t e e r e d  I t should  be r e c o g n i z e d  that a l l notices  I n one telephone i n t e r v i e w by t h i s by the parent t h a t no n o t i c e had been  The c h i l d i n t h i s case had Marfan's syndrome w i t h secondary  s c o l i o s i s and the mother would have r e f u s e d p e r m i s s i o n of the program.  i f she had known  I n an e a r l i e r study a t SFHD (Ladner 1978) 3 o f 29 (10  p e r c e n t ) s t a t e d t h a t they had n o t r e c e i v e d In the telephone i n t e r v i e w s were many v o l u n t a r y gram.  accep-  The use o f a r e f u s a l o n l y consent however may c o n t r i b u t e t o  of s c r e e n i n g  received.  The r e f u s a l r a t e f o r i n i -  expressions  the i n t r o d u c t o r y  letter.  conducted by t h i s i n v e s t i g a t o r  of a p p r e c i a t i o n f o r the s c r e e n i n g  there pro-  I n s e v e r a l cases these were by p a r e n t s who had c h i l d r e n w i t h no  confirmed s c o l i o t i c d i s e a s e but who had been r e f e r r e d f o r o r t h o p e d i c c o n s u l t a t i o n i n c l u d i n g X-rays. c r e a t e d by t h i s p r o c e s s . program were n o t s o l i c i t e d  There appeared t o be no resentment  S p e c i f i c opinions  about a c c e p t a b i l i t y of the  from p a r e n t s or p h y s i c i a n s .  101  The s e l f - c o n s c i o u s n e s s of the screenees has been a minor  diffi-  c u l t y but not a drawback to s c r e e n i n g i n terms of r e f u s a l to consent the screenee. to  interpret  As the program has developed  the s t a f f have d e v i s e d ways  the program and d e a l w i t h the screenee i n an assured  o f - f a c t manner which has minimized  by  matter-  the i n s e c u r e r e a c t i o n s of the a d o l -  escents. A c c e p t a b i l i t y i n the s c h o o l d i s t r i c t s among p r i n c i p a l s , t r u s t e e s and p a r e n t s has been r e p o r t e d f a v o r a b l y throughout period.  t i o n by  the s c r e e n i n g  The p o s s i b l e c a n c e l l a t i o n of the program i n the f a l l  because of s h o r t a g e of p h y s i o t h e r a p y s t a f f was those i n the community who  greeted with  were aware of the  i n c l u d i n g members of the Union Board  of H e a l t h .  teachers,  of  1980  consterna-  possibility,  T h i s p o i n t s out  the  i m p l i c a t i o n f o r a h e a l t h d i s t r i c t p u b l i c r e l a t i o n s e f f o r t i f the program i s m o d i f i e d or d e l e t e d i n the f u t u r e . P h y s i c i a n acceptance has s m a l l survey and a t p r e s e n t by t i g a t o r during their  A c c e p t a b i l i t y of  a l s o been demonstrated by an  earlier  the c o o p e r a t i o n r e c e i v e d by t h i s i n v e s -  study.  treatment  To be e f f e c t i v e a treatment must be e f f i c a c i o u s or do more good than harm to those who  f u l l y comply w i t h i t s recommendations.  as e f f i c a c y , e f f e c t i v e n e s s has another the treatment  by  As w e l l  component, t h a t of acceptance  those to whom i t i s o f f e r e d .  T h i s aspect of e f f e c t i v e n e s s of treatment  can be c o n s i d e r e d i n  r e l a t i o n to the numbers of known r e f u s a l s to comply w i t h recommended treatments  of  as w e l l as r e f u s a l s to a c c e p t r e f e r r a l  to the p h y s i c i a n  ( e i t h e r g e n e r a l p r a c t i t i o n e r or s p e c i a l i s t ) .  The r e f u s a l of 2 of 169  r e f e r r a l s f o r a r a t e of 1.2 p e r c e n t i n d i c a t e s a h i g h compliance r a t e compared t o o t h e r s r e p o r t e d i n the l i t e r a t u r e .  Compliance w i t h the  recommendations o f the f a m i l y p h y s i c i a n f o r continued o b s e r v a t i o n was 95 p e r c e n t . The l e v e l of compliance w i t h the recommendation o f the o r t h o p e d i c s p e c i a l i s t was 73 p e r c e n t c o n s i d e r i n g r e j e c t i o n of any of the recommendations o f t h i s p h y s i c i a n as non-compliance.  I n 68  percent  (15 of 22 ) o f the i n s t a n c e s the non-compliance was w i t h the recommend a t i o n t o r e t u r n f o r a f u r t h e r examination. cases  I n the m a j o r i t y of these  t h e r e had been no s i g n i f i c a n t p r o g r e s s of the curve t o t h a t p o i n t .  I n f o u r cases treatment  t h e r e was f a i l u r e t o accept  the recommendation f o r brace  ( t h r e e o u t r i g h t r e f u s a l s , one a f t e r r e c e i v i n g her b r a c e ) .  For the o r t h o p e d i c p o s i t i v e s  (N = 40) t h i s i s a r a t e of 10 p e r c e n t and  44.4 p e r c e n t of those f o r whom b r a c i n g was recommended  (N = 9 ) .  This  i n d i c a t e s a q u e s t i o n a b l e l e v e l o f a c c e p t a b i l i t y o f b r a c i n g and i s s i g n i f i c a n t because the primary  g o a l o f the s c r e e n i n g program was to a p p l y  b r a c i n g as an a l t e r n a t i v e t o s u r g e r y . The recommendation f o r s u r g e r y has been r e j e c t e d by t h r e e (N = 9 ) . tic  In one of the these cases  girls  the g i r l c o n t i n u e s under c h i r o p r a c -  c a r e and i s o c c a s i o n a l l y seen by the g e n e r a l p r a c t i t i o n e r  who  r e p o r t s a curve o f 38° which i s d i s f i g u r i n g but a p p a r e n t l y a c c e p t a b l e , to  the g i r l  (now 17) and h e r p a r e n t s .  V a l i d i t y of the t e s t V a l i d i t y of the s c r e e n i n g t e s t i n use a t SFHD has been  assessed  103  i n terms of how  w e l l the r e s u l t s of s c r e e n i n g have r e l a t e d to the d i a g -  n o s t i c measure. The  s e n s i t i v i t y of the s c r e e n i n g t e s t was  f o u r years of the program. the range was  When i t was  26.2  p e r c e n t over  c a l c u l a t e d on a y e a r l y b a s i s  from a h i g h of 38 p e r c e n t i n 1977-78 to a low of 11  c e n t i n 1979-80.  This s e n s i t i v i t y  i s unacceptably  low.  p e r c e n t minimal l e v e l of s e n s i t i v i t y s h o u l d be reached 1978).  Although  per-  At l e a s t a 75 (Howell e t a l .  Of p a r t i c u l a r i n t e r e s t i s the s i g n i f i c a n c e of the t r e n d to  s e n s i t i v i t y which may over  have i n d i c a t e d d e c l i n i n g s c r e e n  by t h i s s c r e e n i n g i t must be  t h a t s c o l i o s i s i s a l s o i d e n t i f i e d by  lower  competency.  70 p e r c e n t of the c h i l d r e n w i t h 11° or g r e a t e r  curves a p p a r e n t l y were missed  the  scoliotic  remembered  the o b s e r v a t i o n s of o t h e r s  and  a l s o t h a t many curves are not s i g n i f i c a n t h e a l t h problems so t h a t miss i n g them i s not as c r i t i c a l as would be the case i n s c r e e n i n g f o r other d i s e a s e s more l i f e - t h r e a t e n i n g . The  s p e c i f i c i t y of the s c r e e n i n g t e s t i s 98.4  percent which  meets the c r i t e r i o n of Howell e t a l . (1978) of a t l e a s t 95 The  127  percent.  f a l s e p o s i t i v e s which g i v e an o v e r r e f e r r a l r a t e of  p e r c e n t i s a concern because of the r e s o u r c e s used i n unnecessary n o s t i c t e s t i n g and p o s s i b l y treatment and  the time l o s t i n the process  probably  two  reasons why  the h e a l t h d i s t r i c t .  as w e l l as the a n x i e t y  of n e e d l e s s  o v e r r e f e r r a l was  First  follow-up.  75.1 diag-  generated  There are  not c r e a t i n g d i f f i c u l t i e s i n  there were no d i r e c t c l i e n t c o s t s because  of the M e d i c a l S e r v i c e s P l a n and  second, p h y s i c i a n s were i n ample supply  and  readily available.  In c o n s i d e r i n g t h i s h i g h f a l s e p o s i t i v e r a t e i t  may  be u s e f u l to r e c a l l t h a t when a d i s e a s e i s i n f r e q u e n t i n the  p o p u l a t i o n - l i k e s c o l i o s i s - even a s c r e e n i n g t e s t w i t h h i g h  specificity  (and  of  the r a t e i s 98.4  positives  (Friedman  p e r c e n t ) w i l l y i e l d a h i g h percentage  1974).  I t should a l s o be noted  false  that Wilson  and  Jungner a d v i s e d t h a t a f a i r l y h i g h f a l s e p o s i t i v e r a t e i s a c c e p t a b l e but the f a l s e n e g a t i v e r a t e should be low. 75.1  A f a l s e p o s i t i v e r a t e of  p e r c e n t appears more than " f a i r l y h i g h " however.  The  o v e r r e f e r r a l f o r f o u r y e a r s of s c r e e n i n g a r e estimated a t which i s not a f o r m i d a b l e sum  c o s t s of  $6,324.63,  i n terms of other h e a l t h c a r e program  costs. U n d e r r e f e r r a l s are c a l c u l a t e d the missed  cases.  at 1.5  I t has been suggested  percent.  This represents  t h a t an u n d e r r e f e r r a l r a t e of  l e s s than 5 p e r c e n t i s sometimes c o n s i d e r e d an a c c e p t a b l e percentage f a l s e negatives  ( S t a n g l e r et a l . 1980).  The p o s i t i v e p r e d i c t i v e power i s the f i g u r e of i n t e r e s t p h y s i c i a n s who cases was  to see i n the c h i l d r e n r e f e r r e d  to them.  It  p e r c e n t f o r the s c r e e n i n g program a t SFHD, which meant t h a t  t h r e e out of f o u r times  the r e f e r r a l was  needless.  p r e d i c t i v e v a l i d i t y of the s c r e e n i n g t e s t was f i g u r e i n d i c a t i n g 97 out of every 100 f i e d by  to  see r e f e r r a l s as i t r e p r e s e n t s the p r o p o r t i o n of t r u e  they might expect  24.9  of  However, the  97 p e r c e n t , an  c h i l d r e n were c o r r e c t l y  overall  acceptable identi-  the s c r e e n i n g p r o c e s s . T h i s s c r e e n i n g t e s t has  i d e n t i f i e d a sample of o r t h o p e d i c a l l y  p o s i t i v e c h i l d r e n i n a sex d i s t r i b u t i o n s i m i l a r literature.  The  f i n d i n g t h a t the r a t i o i s 1:9  i m p l i c a t i o n s f o r program m o d i f i c a t i o n .  to t h a t r e p o r t e d i n the (male to female)  has  None of the t r e a t a b l e curves  have o c c u r r e d i n males i n f o u r y e a r s of s c r e e n i n g a p o p u l a t i o n of  8010  children.  In other areas such as Edmonton, g i r l s o n l y are  screened.  A s i m i l a r approach c o u l d be c o n s i d e r e d i n SFHD, e f f e c t i v e l y h a l v i n g the p o p u l a t i o n t o be  screened.  The SFHD s c r e e n i n g program has not found  the number of o r t h o -  p e d i c a l l y p o s i t i v e screenees which would be expected prevalence figures i n s i m i l a r screening populations. p e r c e n t i s much lower (Hornung 1977)  than t h a t found  from p u b l i s h e d The r a t e of  i n Vancouver's p i l o t  which r e p o r t e d a r a t e of 4 p e r c e n t  0.6  program  (41 i n 1006).  Con-  t r a s t e d to the major study i n M o n t r e a l  (Rogala e t a l . 1978)  p e r c e n t of the screened p o p u l a t i o n had  curves g r e a t e r than 10°, SFHD's  p r e v a l e n c e i s n o t a b l y low.  where 2  The p r e v a l e n c e of t r e a t a b l e curves i n the  study p o p u l a t i o n at a r a t e of 0.1498 p e r c e n t or about one-half the p r e v a l e n c e expected  (0.275 or 0.3  p e r c e n t ) i s another q u e s t i o n a b l e f i n d i n g  but must be viewed w i t h c a u t i o n because of the unknown treatment  status  of other s c o l i o s i s curve cases i n the community. The  concern i s of course t h a t curves t h a t a r e most " a t r i s k " ,  w i t h p o t e n t i a l f o r p r e v e n t i v e treatment  Availability  are b e i n g  missed.  of r e s o u r c e s  There i s no q u e s t i o n t h a t the e x i s t e n c e of t h i s s c r e e n i n g p r o gram a t SFHD has time  taken a c o n s i d e r a b l e p o r t i o n o f h e a l t h d i s t r i c t  staff  (see T a b l e IX) as w e l l as u s i n g o t h e r community h e a l t h s e r v i c e s  such as g e n e r a l p h y s i c i a n , o r t h o p e d i s t , X-ray and p h y s i o t h e r a p y X, X I I , X I I I and XIV). the demand f o r these  There has been no apparent  problem i n meeting  services.  The q u e s t i o n of c o s t s generated not been e v a l u a t e d .  (Tables  The h e a l t h d i s t r i c t  and a l t e r n a t i v e s foregone  has  at the p r e s e n t time has begun  106  the p r o c e s s of zero-based b u d g e t i n g . , In p r e p a r a t i o n f o r t h i s each p r o f e s s i o n a l group  i n the h e a l t h d i s t r i c t  and  l e v e l s of s e r v i c e which must be p r o v i d e d .  the minimal  on s t a f f  i s i d e n t i f y i n g program  priorities  The  figures  time spent i n s c o l i o s i s s c r e e n i n g w i l l be u s e f u l i n t h i s p r o -  cess of c h o o s i n g between a l t e r n a t i v e programs. The one apparent d e f i c i e n c y i d e n t i f i e d has been l a c k o f a central  clinic  to r e c e i v e r e f e r r a l s f o r a l l screening p o s i t i v e s .  Such a  c l i n i c would enable outcomes to be r e a d i l y a v a i l a b l e f o r the m o n i t o r i n g of s c r e e n i n g v a l i d i t y .  S t a f f t r a i n i n g i n s c r e e n i n g would be  facilitated  by a c l i n i c where o r t h o p e d i c p o s i t i v e s c o u l d be seen c l i n i c a l l y .  The  f o l l o w - u p o f p o s i t i v e s c o u l d be ensured w i t h a c a l l - b a c k system.  Proper  d i a g n o s t i c X-rays would be a s s u r e d .  I f treatment were a l s o handled i n  a c l i n i c approach more s u c c e s s f u l b r a c i n g treatment c o u l d be In t h i s way used  some group  possible.  support f o r those r e q u i r i n g b r a c i n g c o u l d be  to h e l p the b r a c i n g c a n d i d a t e work through her acceptance of the  treatment. The a r e a of o r t h o s i s i s the one of most concern.  At the p r e s e n t  time t h i s s e r v i c e f o r the f i t t i n g of the Milwaukee b r a c e i s a v a i l a b l e from a c e r t i f i e d o r t h o t i s t i n Vancouver.  During the p e r i o d covered by  t h i s study t h e r e were gaps i n o r t h o t i c s e r v i c e o f f e r e d . f o r s c o l i o s i s appears c h i l d r e n i n B.C.  orthotics  to be h i g h l y s p e c i a l i z e d and 90 p e r c e n t of the  come to t h i s one o r t h o t i s t i n Vancouver,  q u e s t i o n the problem  As  one  might  generated i f more b r a c i n g treatment r e s u l t s  from  expanded s c r e e n i n g e f f o r t s s h o u l d the program become p r o v i n c e w i d e . The same problem  c o u l d be c r e a t e d through d e f i c i e n c y i n o r t h o -  pedic expertise i n s c o l i o t i c  treatment.  P e d i a t r i c o r t h o p e d i s t s are  107  rare  (3 of 108  p r a c t i c i n g orthopedists  i n the Lower Mainland and  i n B.C.)  and  these are  V i c t o r i a areas so t h a t c o n s i d e r a b l e  c o u l d be generated f o r p a t i e n t s throughout the p r o v i n c e sultation.  The  l e v e l of e x p e r t i s e i n d i a g n o s i s  average f a m i l y p h y s i c i a n i s unknown. general  located difficulty  seeking  a con-  of s c o l i o s i s f o r  In the SFHD program many of  p r a c t i t i o n e r s r e f e r r e d the c h i l d d i r e c t l y to an  the the  orthopedist  w i t h o u t X-ray examination i n s p i t e of the h e a l t h d i s t r i c t ' s  recommenda-  t i o n contained  physical  e x a m i n a t i o n was  i n the l e t t e r of r e f e r r a l .  In some cases no  done e i t h e r , which would i n d i c a t e some  p h y s i c i a n confidence  i n this  area.  questionable  108  CHAPTER VI  CONCLUSION  As Chamberlain has s a i d so a p t l y i n h i s paper on e v a l u a t i o n o f screening: The d e c i s i o n on whether or not t o p r o v i d e a s c r e e n i n g s e r v i c e to c o n t r o l one or more d i s e a s e s can seldom be an easy one f o r the h e a l t h a d m i n i s t r a t o r . He n o t o n l y has t o d e v i s e an e f f i c i e n t method o f o r g a n i z a t i o n w i t h i n the e x i s t i n g h e a l t h care system, b u t he a l s o has t o measure the t o t a l c o s t of t h i s and d e c i d e whether the e x t e n t of b e n e f i t l i k e l y t o be achieved i s g r e a t e r than t h a t which c o u l d be d e r i v e d from a l t e r n a t i v e ways of spending h i s s c a r c e r e s o u r c e s . To make t h i s d e c i s i o n r a t i o n a l l y r e q u i r e s a s c i e n t i f i c e v a l u a t i o n o f s c r e e n i n g and e a r l y treatment, t a k i n g i n t o account a l l the f a c t o r s which can i n f l u ence i t s s u c c e s s . (Chamberlain 1979, p. 757) The  same c h a l l e n g e  a program should  confronts  the h e a l t h a d m i n i s t r a t o r  be c o n t i n u e d .  f o r program p l a n n i n g  I n an e f f o r t  i n d e c i d i n g whether  to p r o v i d e  a rational  basis  a t SFHD c r i t e r i a were a p p l i e d to the s c o l i o s i s  s c r e e n i n g program and the r e s u l t s from t h a t program f o r the 8010 c h i l d r e n screened from September 1976 to June 1980.  The f o l l o w i n g  hypothesis  was proposed f o r the s t u d y : E v a l u a t i o n of the r e s u l t s o f f o u r years  of s c o l i o s i s  screening  a t Simon F r a s e r H e a l t h D i s t r i c t w i l l s u b s t a n t i a t e c o n t i n u a t i o n o f the screening  program.  The  c o n c l u s i o n t h a t the evidence does not support  program con-  t i n u a t i o n i s reached on the f o l l o w i n g b a s i s . First, iotic  the o r i g i n a l program o b j e c t i v e o f i d e n t i f i c a t i o n of s c o l -  curves a t a stage when the Milwaukee b r a c e c o u l d be a p p l i e d and  109 surgery avoided, has not been achieved.  S i x operations f o r s c o l i o s i s  have occurred i n the screening population.  I n f i v e of these s i x cases  bracing was e i t h e r unsuccessful or unacceptable and thus d i d not prevent the surgery. The c r i t e r i o n of a c c e p t a b i l i t y of the screening test has been w e l l met at SFHD.  The screening test has been h i g h l y acceptable to  parents and c h i l d r e n with few exceptions.  The r e f u s a l rate was e s t i -  mated at 0.3 percent however i t i s recognized that a l l parents were not aware of the screening date to o f f e r dissent because notices had not been received. This has not been a problem and t h i s h i g h l y v i s i b l e program i s a l s o well-supported by school d i s t r i c t personnel, the Union Board of Health and personnel of the h e a l t h d i s t r i c t . The evidence from t h i s study suggests that the c r i t e r i o n that a screening program should be o f f e r e d only i f acceptable treatment i s a v a i l a b l e to those who r e q u i r e i t , has not been f u l f i l l e d .  Active  treatment f o r s c o l i o s i s i s recognized as bracing or surgery.  In t h i s  screening population bracing was recommended f o r nine c h i l d r e n and was refused i n three cases. after receiving i t .  Another c h i l d rejected the brace immediately  E s s e n t i a l l y then four of the nine (44.4 percent)  candidates f o r bracing d i d not accept t h i s treatment.  Surgery was  recommended f o r nine c h i l d r e n and i n three cases (33.3 percent) t h i s recommendation was not accepted. The c r i t e r i o n that the screening test i s v a l i d may be assessed by the l e v e l of s e n s i t i v i t y and s p e c i f i c i t y achieved by that test as w e l l as o v e r r e f e r r a l and u n d e r r e f e r r a l rates and the p r e d i c t i v e value of the t e s t .  A s e n s i t i v i t y of 26.2 percent was derived using s c o l i o s i s  110 p r e v a l e n c e from the l i t e r a t u r e t o g i v e a " t o t a l d i s e a s e d " e s t i m a t e f o r the f o u r f o l d  table.  Using t h i s s t a n d a r d o n l y one c h i l d  s c o l i o s i s i s r e c o g n i z e d i n t h i s s c r e e n i n g program.  i n four with  S p e c i f i c i t y was  e s t i m a t e d a t 98.4 percent, u n d e r r e f e r r a l a t 1.5 p e r c e n t and t o t a l d i c t i v e v a l u e a t 96.9 p e r c e n t .  While  pre-  s p e c i f i c i t y , u n d e r r e f e r r a l and  o v e r a l l p r e d i c t i v e v a l u e a r e a c c e p t a b l e , the 75.1 p e r c e n t r a t e f o r o v e r r e f e r r a l i s a concern because of the d i r e c t c o s t s generated s a r y d i a g n o s t i c and p o s s i b l y treatment o v e r r e f e r r a l a r e harder  services.  i n unneces-  I n d i r e c t costs of  t o e s t i m a t e b u t do occur because of a n x i e t y and  time l o s s and p o s s i b l y due to unnecessary  exposure to r a d i a t i o n .  P u b l i s h e d p r e v a l e n c e f i g u r e s o f 2 p e r c e n t to 4 p e r c e n t u s i n g the same age group, s c r e e n i n g t e s t and d i a g n o s t i c s t a n d a r d have been widely reported.  P r e v a l e n c e o f s c o l i o s i s a t SFHD was e s t i m a t e d a t 0.6  p e r c e n t f o r t h e f o u r y e a r s of the program under review. adjustments  made t o account  f o r known s c o l i o s i s  I n s p i t e of  i n this population  a p a r t from the s c r e e n i n g sample, t h i s low f i g u r e c a l l s i n t o q u e s t i o n the v a l i d i t y  of the s c r e e n i n g t e s t .  or o t h e r v a r i a b l e s were not apparent those w i t h t h e h i g h e r  Socio-economic,  ethnic differences  between SFHD's p o p u l a t i o n and  prevalence.  T h i s study has not attempted  t o e x p l o r e the reasons  f o r the  i d e n t i f i c a t i o n of fewer t r u e p o s i t i v e s i n t h i s s c r e e n i n g p o p u l a t i o n . The l a s t  c r i t e r i o n a p p l i e d t o SFHD's program was t h a t r e s o u r c e s  were a v a i l a b l e t o c a r r y out the program and to t r e a t cases found by screening.  While  p r o v i s i o n of s t a f f f o r s c r e e n i n g can be a major  r e s o u r c e problem t h e r e has been no evidence  t h a t t h i s was a d i f f i c u l t y  d u r i n g the p e r i o d o f t h i s study a p a r t from a b r i e f p e r i o d when the  Ill  d i s t r i c t was  without  two  physiotherapists.  examines i t s p r i o r i t i e s under a new  As  the h e a l t h  district  system of f i s c a l management the  p r i o r i t y g i v e n to s c o l i o s i s s c r e e n i n g i s b e i n g r e a s s e s s e d . mates of s t a f f The  time and  aspect  of the c r i t e r i o n t h a t a v a i l a b l e r e s o u r c e s i n two  areas.  First,  tage i n the o p e r a t i o n of t h i s s c r e e n i n g program and Such a r e s o u r c e would have enabled  to be m o n i t o r e d , ensured s t a n d a r d  nel.  Second, o r t h o t i c s e r v i c e has  f o u r years  i n i t s continuing  f o r accurate  for t r a i n i n g screening  diagperson-  been an area of concern d u r i n g  of the s c r e e n i n g program.  i e n c e d o r t h o t i c s e r v i c e was  disadvan-  the s c r e e n i n g program  X-rays n e c e s s a r y  n o s i s of s c o l i o s i s , and been a r e s o u r c e  for treat-  the absence of  f o r r e f e r r a l of a l l s c r e e n i n g p o s i t i v e s has been a  evaluation.  esti-  c o s t w i l l have a p l a c e i n t h i s assessment.  ment be a v a i l a b l e i s q u e s t i o n a b l e a clinic  The  the  There were p e r i o d s when exper-  not a v a i l a b l e .  I n the l o n g term t h i s  may  have d e t r a c t e d from b r a c i n g as a treatment a l t e r n a t i v e . In summary, c o n t i n u a t i o n of the s c o l i o s i s s c r e e n i n g program i s not supported acceptable,  because although  the s c r e e n i n g  t e s t and program have been  the a c c e p t a b i l i t y of treatment by b r a c i n g and  questionable.  The  low s e n s i t i v i t y and h i g h o v e r r e f e r r a l r a t e of  screening test c a l l into question i t s v a l i d i t y . a v a i l a b l e resources  i s not  o r t h o t i c s e r v i c e s and d i a g n o s i s and  surgery i s  The  c r i t e r i o n of  f u l f i l l e d because of l a c k of  a clinic  the  coordinated  f o r r e f e r r a l of s c r e e n i n g p o s i t i v e s f o r  treatment.  General Because the h y p o t h e s i s  Recommendations of t h i s study has  not been supported  i s recommended t h a t the s c o l i o s i s s c r e e n i n g program at SFHD be  it  discontinued.  112 T h i s d e c i s i o n i s r a t i o n a l i z e d by review  of the r e s u l t s of the program  u s i n g the f o u r p r i n c i p a l e v a l u a t i v e c r i t e r i a of s c r e e n i n g and by l a c k of evidence The  t h a t other c r i t e r i a to v a l i d a t e s c r e e n i n g are  the  fulfilled.  i n t r o d u c t i o n of the s c o l i o s i s s c r e e n i n g program to other  p r o v i n c i a l h e a l t h d i s t r i c t s would not appear a d v i s a b l e because of concerns  evidenced  and v a l i d i t y  i n t h i s study about a c c e p t a b i l i t y of the  of the s c r e e n i n g t e s t .  Even more important  the  treatment  i f screening  were extended i n t o the p r o v i n c i a l system, would be the f u l f i l l m e n t the c r i t e r i o n of a v a i l a b l e r e s o u r c e s . o r t h o p e d i c s p e c i a l i s t s and f r u s t r a t i o n and  The p r o v i n c i a l d i s t r i b u t i o n of  o r t h o t i s t s i s unequal,  and  considerable  a n x i e t y as w e l l as c o s t c o u l d be c r e a t e d by  a program w i t h the p o t e n t i a l f o r a h i g h r a t e of  to the h e a l t h d i s t r i c t  d i s t r i c t p e r s o n n e l , p h y s i c i a n s and and wide acceptance relations  offering  overreferral.  In the event of d i s c o n t i n u a t i o n of the program the should be i n t e r p r e t e d c a r e f u l l y  general p u b l i c .  rationale  staff,  The h i g h  of the program warrant a c a r e f u l l y planned p u b l i c  effort.  should be taught about s c o l i o s i s and curves may  be r e f e r r e d  so are most l i k e l y  curve  a curved s p i n a l column i n the normal  I t i s not intended  they r e f e r apparent  s i g n s of a s c o l i o t i c  regularly  and h i p l e v e l s , unequal w a i s t a n g l e s , r i b  humps, a t i l t e d p e l v i s and of t h e i r d u t i e s .  T h i s group  c l o t h i n g and b a t h i n g s u i t s  to d e t e c t obvious  such as unequal shoulder  district  the s i g n s of the c o n d i t i o n so t h a t  to the p u b l i c h e a l t h . n u r s e .  of t e a c h e r s see a d o l e s c e n t s i n gym and  school visibility  As an a l t e r n a t i v e p h y s i c a l e d u c a t i o n t e a c h e r s of the  obvious  of  problems.  t h a t they s c r e e n per se but  course that  113  In the event t h a t the d e c i s i o n i s made t o continue program two recommendations a r e made.  First  the s c r e e n i n g  t h a t the s c r e e n i n g of g i r l s  o n l y would reduce the time and c o s t o f the program w i t h n e g l i g i b l e on the number of t r e a t a b l e cases d e t e c t e d .  Second, the e s t a b l i s h m e n t o f  a c e n t r a l c l i n i c f o r r e f e r r a l o f a l l s c r e e n i n g p o s i t i v e s should contingency  o f program c o n t i n u a t i o n w i t h  effect  the p r o v i s o t h a t  be a  screening  r e s u l t s w i l l meet s e t e v a l u a t i v e c r i t e r i a o r the program w i l l be d i s continued.  Recommendations f o r F u r t h e r  Study  E v a l u a t i v e s t u d i e s of the s c r e e n i n g t e s t f o r s c o l i o s i s have been c a r r i e d out i n o t h e r p a r t s o f Canada. c a r r y i n g out a study  C o n s i d e r a t i o n may be g i v e n t o  o f the v a l i d i t y and r e l i a b i l i t y of the s c r e e n i n g  t e s t u s i n g SFHD s t a f f and s e l e c t e d s c h o o l c h i l d r e n .  There i s a v a i l a b l e  known X-ray s t a t u s of a sample of c h i l d r e n i n the d i s t r i c t  to f a c i l i t a t e  such a study. The classified  s t a t u s o f c h i l d r e n who were s c r e e n i n g p o s i t i v e but who were as normal without  r a d i o g r a p h i c evidence  should be i n v e s t i g a t e d to determine t h e i r p r e s e n t  by the p h y s i c i a n c l i n i c a l status.  Availability  of the r a d i o g r a p h i c s t a t u s of these  could e f f e c t  the e s t i m a t i o n of s e n s i t i v i t y of the s c r e e n i n g  A study  38 s c r e e n i n g p o s i t i v e s  s h o u l d be done on why b r a c i n g has n o t been  test. acceptable  to the c h i l d r e n who r e j e c t e d t h i s form of treatment i n t h i s program. Such a study w i l l be u s e f u l i n t h e f u t u r e approach t o b r a c i n g as an acceptable the study  treatment.  Because of the s m a l l number a v a i l a b l e at SFHD  c o u l d i n v o l v e c h i l d r e n from other  areas.  And f i n a l l y . a study  of the s t a t u s o f the s c r e e n i n g r e f u s a l s  would be h e l p f u l i n a r r i v i n g a t a more a c c u r a t e p r e v a l e n c e s c o l i o s i s i n SFHD. the reason  rate f o r  Some o f t h i s group i n d i c a t e d s p i n a l d i s e a s e as  f o r r e f u s a l and i t would be p e r t i n e n t to know how many were  i d i o p a t h i c s c o l i o s i s w i t h an 11° or g r e a t e r  curvature.  115  LIST OF REFERENCES  B l o u n t , Walter P. 1981. The v i r t u e of e a r l y treatment Scoliosis. J . Bone J o i n t Surg. 63A: 335-336.  of I d i o p a t h i c  Brooks, H. L. 1977. I d i o p a t h i c s c o l i o s i s - r e s u l t s of a p r o s p e c t i v e study. In S c o l i o s i s : proceedings of a f i f t h symposium, pp. 11-30. E d i t e d by P. A. Zorab. London: Academic P r e s s . 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The e f f e c t of an e x e r c i s e program on change i n curve i n a d o l e s c e n t s w i t h minimal i d i o p a t h i c scoliosis. Phys. Ther. 59: 759-763. T a y l o r , T. K. F.; B u s h e l l , G.; and Ghosh, W. F. 1978a. S c h o o l s c r e e n i n g for s c o l i o s i s : a Pandora's box. Aust. N.Z. J . Surg. 48: 2-3. T a y l o r , T. K. F.; B u s h e l l , G.; and Ghosh, W. F. 1978b. S c h o o l s c r e e n i n g for s c o l i o s i s : a l o o k i n s i d e Pandora's box. A u s t . N.Z. J . Surg. 48: 441-443. T i b b i t s , C a r o l e W. 5: 11-20. Torell,  1980.  Adolescent i d i o p a t h i c s c o l i o s i s .  Nurse  Pract.  Gunnar; N o r d w a l l , Anders; and Nachemson, A l f . 1981. The changing p a t t e r n of s c o l i o s i s treatment due to e f f e c t i v e screening. J . Bone J o i n t Surg. 63A: 337-341.  T r e d w e l l , Stephen. 1981. Workshop p r e s e n t a t i o n on S c o l i o s i s . U n i v e r s i t y of V i c t o r i a , March 14, 1981. V e r r i e r , M o l l y C.; S h i l l i n g t o n , E. R.; Wright, T. A.; Crawford, J . S.; and W i l l i a m s , J . I . 1979. T e s t i n g the r e l i a b i l i t y and v a l i d i t y of s c r e e n i n g methods f o r s c o l i o s i s . A r e p o r t of the H e a l t h Research U n i t . U n i v e r s i t y of Toronto, September, 1979. (Mimeographed.) W i c k e r s , Frank C.; Bunch, W i l t o n H.; and B a r n e t t , P. M. 1977. P s y c h o l o g i c a l f a c t o r s i n f a i l u r e to wear the Milwaukee b r a c e f o r treatment of i d i o p a t h i c s c o l i o s i s . C l i n . Orthop. 126: 62-66.  W i l l i a m s , J . Ivan, and T i c e , Susan. 1980. A f o l l o w - u p study of grade 6 s t u d e n t s screened f o r s c o l i o s i s 1977-78. A r e p o r t to the Scarborough H e a l t h Department. H e a l t h Care Research U n i t . U n i v e r s i t y of Toronto, September, 1980. (Mimeographed.) W i l s o n , J . M. G., and Jungner, F. of s c r e e n i n g f o r d i s e a s e . WHO.  1968. The p r i n c i p l e s and p r a c t i c e P u b l i c H e a l t h Papers No. 34, Geneva  Wingate, L y d i a . 1977. A model s c o l i o s i s s c r e e n i n g program f o r the urban p o p u l a t i o n of a l a r g e c i t y . T h e s i s f o r degree of Master of S c i e n c e , Albany M e d i c a l C o l l e g e .  121  APPENDIX A  I n t r o d u c t o r y L e t t e r to Family  APPENDIX B  I n t e r v i e w Format  Parent  contact/interview  H e l l o , I am B e t t y Wynne, a P u b l i c H e a l t h Nurse a t Simon F r a s e r Health D i s t r i c t .  I am c a l l i n g you a t t h i s  i n f o r m a t i o n about what happened a f t e r was i d e n t i f i e d  results  as  s c r e e n i n g s i n c e 1976 and f e e l i t i s t i m e l y t o assess the  which were made.  what was the outcome of the  While no i n d i v i d u a l  p u b l i s h e d I would a p p r e c i a t e some d e t a i l s occurred  having  At Simon F r a s e r H e a l t h U n i t we have conducted  of our program by d e t e r m i n i n g  referrals  your c h i l d  at school i n  possible scoliosis. scoliosis  time t o ask f o r f u r t h e r  after  the r e f e r r a l  forscoliosis.  may not wish t o answer these q u e s t i o n s is entirely  voluntary.  1) D i d you take your c h i l d  about the follow-up I recognize  and that your  You have the r i g h t  A f t e r your r e c e i v e d the r e f e r r a l  i n f o r m a t i o n w i l l be  physician?  or Yes  No  2) Was an X-ray done?  or Yes  What was t h e r e s u l t ?  t h a t you  participation  t o withdraw a t any time.  letter:  t o your f a m i l y  which  No  125 3) What was recommended f o r f u t u r e  follow-up?  P o s s i b i l i t i e s are: a) R e f e r r a l t o an o r t h o p e d i c surgeon?  or Yes  No  Name: b) Continued  o b s e r v a t i o n by f a m i l y p h y s i c i a n  or Yes  c) No f u r t h e r f o l l o w - u p r e q u i r e d  or Yes  d) Can't remember  No  No  or Yes  No  4) I f r e f e r r a l t o an o r t h o p e d i c surgeon was made, what was h i s recommendation? a) Continued  observation:  at i n t e r v a l s of  .  b) X-rays  or Yes  No  a t i n t e r v a l s of c) B r a c i n g  .  (type)  , Exercises  d) Surgery  .  .  T h i s has been most h e l p f u l . and  ;  May I c o n t a c t your p h y s i c i a n  the o r t h o p e d i c surgeon  f o r f u r t h e r information?  or Yes  No  ( I f yes) I w i l l m a i l a consent  Thank you v e r y much.  form f o r you t o complete and r e t u r n .  APPENDIX C  Consent f o r P h y s i c i a n Contact  128  APPENDIX D  I n t r o d u c t o r y L e t t e r to P h y s i c i a n  APPENDIX E  Q u e s t i o n n a i r e to P h y s i c i a n  132  I am c o n t i n u i n g t o observe Yes  o r No  of  at intervals  ;  T h i s p a t i e n t no l o n g e r r e q u i r e s o b s e r v a t i o n Yes and  or No  can be c a t e g o r i z e d a s :  (i)  minimal s c o l i o s i s  (less  (ii)  stabilized  (iii)  n o n - s c o l i o t i c Yes  (iv)  or  than 10°)  curve of  degrees or No  T h i s c h i l d i s b e i n g f o l l o w e d by an o r t h o p e d i c  surgeon  Name: * I f treatment  f o r s c o l i o s i s was  B r a c i n g was a p p l i e d (if s t i l l Surgery  instituted: (date) f o r  (lengh o f time)  i n brace p l e a s e i n d i c a t e c o n t i n u i n g )  by H a r r i n g t o n Rod procedure was performed  .  Other Treatment:  .  Is f u r t h e r i n f o r m a t i o n o b t a i n a b l e by c o n t a c t i n g another Who i s  physician? .  :  We a p p r e c i a t e your a s s i s t a n c e i n our program review.  I f you would  l i k e a summary o f our e v a l u a t i o n p l e a s e i n d i c a t e by a check here and  a copy o f our s c o l i o s i s program e v a l u a t i o n w i l l be m a i l e d  t o you  i n the f a l l .  B e t t y Wynne Nursing Supervisor.  APPENDIX F  C e r t i f i c a t e of  Approval  135  APPENDIX G  L e t t e r of P e r m i s s i o n  

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