Optimizing Patient Care

Scoliosis E-Newsletter

Issue II - 06.2017

In This Issue...

  1. Optimizing Patient Care
  2. Scoliosis Screening
  3. Recommendations
  4. Implementation
  5. Clinical Considerations
  6. Resources

Optimizing Patient Care: Scoliosis Screening


Optimizing Patient Care: Incorporating "Choosing Wisely®" Recommendations into Practice

The IAFP is pleased to continue the e-newsletter series regarding incorporating "Choosing Wisely®" recommendations into practice. Each newsletter will have a specific focus, with the second being Scoliosis Screening. This issue, along with each e-newsletter, will contain recommendations, updates, links to resources, and strategies for you to implement in your practice.

This newsletter was created by the Illinois Academy of Family Physicians and is made possible by funds received from:

  • American Academy of Family Physicians through its program, The Family Medicine Philanthropic Consortium
  • Blue Cross and Blue Shield of Illinois
  • The Telligen Community Initiative

Online Education Videos

 In addition to the e-newsletter series, IAFP now has two online enduring educational offerings:

  • Optimizing Patient Care. The first being Optimizing Patient Care: Incorporating "Choosing Wisely®" Into Practice
  • Optimizing Patient Care: Antibiotic Stewardship

Visit IAFP's Education website today to learn more!

Scoliosis Screening

Scoliosis is a lateral curvature of the spine that is most likely to occur during early adolescence (the growth spurt before puberty). Most cases of scoliosis are mild. Certain diseases, such as muscular dystrophy, can cause scoliosis as can congenital, degenerative, or developmental issues. The most common form of scoliosis is idiopathic scoliosis where the origin of the spinal curvature is unknown. Idiopathic scoliosis affects approximately 2 - 4 percent of adolescents. The incidence is about the same in males and females, however, curve progression and need for treatment is more likely in females.

Physical exam includes the Adam's forward bend test and observing the spine for asymmetry of the shoulders, scapulae and hips along with a scoliometer measurement to assess the curve of the spine. Results of the physical exam can guide physicians' decision-making on the need for radiologic testing. Treatment options for adolescents with mild scoliosis include observation and monitoring by X-Ray. For adolescents diagnosed with moderate or severe scoliosis, treatment with a brace or surgery may be necessary.

Screening adolescents for scoliosis had been a routine part of physical exams in schools for decades. There has been growing interest in the medical community in reducing waste within the health care system and reduce harm to patients from tests and procedures that have been shown not to be a necessary part of treatment. There is disagreement within the medical community as to the necessity of screening adolescents for idiopathic scoliosis. Evidence from the literature shows that the forward bend test is unreliable on its own and that screening for idiopathic scoliosis can lead to harm in adolescents. Other evidence from the literature shows benefits in care for patients who have had early screening and detection of idiopathic scoliosis. It is suggested that an overall goal for physicians is to accurately identify adolescents at risk for developing problems associated with scoliosis while avoiding testing and screening adolescents who will likely have no problems from scoliosis.

Scoliosis Screening: Recommendations

As part of the Choosing Wisely® campaign, the American Academy of Family Physicians (AAFP) identified 15 clinical recommendations. The full list of recommendations is available here. The recommendation 14 on scoliosis screening was included in the third phase of the campaign, which included recommendations 11 through 15. The goal of phase three was to identify items common in the practice of family medicine supported by a review of the evidence that would lead to significant health benefits, reduce risks, harms and costs. For each recommendation, evidence was reviewed from appropriate sources such as the Cochrane Collaboration, the Agency for Healthcare Research and Quality and other sources. The AAFP's Commission on Health of the Public and Science and Board of Directors reviewed and approved the recommendations.

Choosing Wisely® Scoliosis Recommendation for Screening Adolescents:

Don't screen adolescents for scoliosis.

There is no good evidence that screening asymptomatic adolescents detects idiopathic scoliosis at an earlier stage than detection without screening. The potential harms of screening and treating adolescents include unnecessary follow-up visits and evaluations due to false positive test results and psychological adverse effects.

USPSTF Recommendation on Screening for Idiopathic Scoliosis in Adolescents

In 2004, the U.S. Preventative Services Task Force (USPSTF) recommended against the routine screening of asymptomatic adolescents for idiopathic scoliosis citing a lack of good evidence that screening benefited patients. Note: This was a change in position from 1996 when the USPSTF concluded that the evidence on the effectiveness of scoliosis screening was inconclusive. Specifically, the USPSTF found:

  • Insufficient evidence that screening asymptomatic adolescents detected idiopathic scoliosis at an earlier stage than detection without screening;
  • Variable accuracy in the use of the forward bending test (with or without a scoliometer);
  • Treatment of idiopathic scoliosis during adolescence led to decreased pain and/or disability in only a small proportion of people;
  • Most of those screened will not progress to a clinically significant form of scoliosis; and
  • Scoliosis needing aggressive treatment, such as surgery, is likely to be detected without screening.
  • Screening for scoliosis led to moderate harms such as, radiation exposure, unnecessary brace wear and emotional stress.

While screenings for adolescent idiopathic scoliosis are not recommended, clinicians should be prepared to evaluate patients for idiopathic scoliosis if parents and/or patients are concerned or if the scoliosis is found inadvertently. For more information see the USPSTF recommendation statement.

Scoliosis Screening: Implementation

It is not yet clear how the recommendation on screening scoliosis in adolescents is being implemented. The Choosing Wisely® campaign has a broad reach worldwide and the recommendations are intended to guide physicians and patients to make evidence-based choices regarding care.

The American Academy of Family Physicians (AAFP) states that the recommendation on scoliosis (as well as other recommendations for clinical preventive services) is:

provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient's family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These recommendations are only one element in the complex process of improving the health of America. To be effective, the recommendations must be implemented.

For additional information, see the June 2016 AAFP publication entitled Summary of recommendations for clinical preventive services.

There is concern among health experts that the recommendations will be implemented too broadly and potentially compromise the health care needs of individual patients. Further, a number of specialty societies disagree that screening adolescents for scoliosis is unnecessary. In 2015, the Scoliosis Research Society (SRS), American Academy of Orthopedic Surgeons (AAOS), Pediatric Orthopedic Society of North America (POSNA) and American Academy of Pediatrics (AAP) released a position statement supporting screening of children for adolescent idiopathic scoliosis (AIS). The positon statement can be found here.

Scoliosis Screening: Clinical Considerations

Talking to Parents and Adolescents About Scoliosis Screening

  • Explain that most cases of idiopathic scoliosis in adolescents are mild and will not need treatment. Further,
    • Screening for scoliosis may not lead to a more accurate diagnosis
    • Screening for scoliosis may lead to harm including unnecessary follow-up visits, tests and treatments and adverse psychological adverse effects.
  • Discuss with patients and parents the importance of working together to make the best, informed choices regarding screening for scoliosis.
  • Remind parents and patients that physicians are prepared to evaluate idiopathic scoliosis should parents and/or adolescents continue to be concerned.  

Online Resources

Choosing Wisely® - National medical specialty societies developed lists of evidence-based recommendations regarding appropriateness of tests and procedures that clinicians and patients should discuss. Additional information is available at:http://www.choosingwisely.org/. Choosing Wisely® is an initiative of the ABIM.

Choosing Wisely® - Screening Tests: When you need them - When you don't. Available at:



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