Keywords congenital abnormalities - public health - spine - scoliosis - mass screening
Introduction
Adolescent idiopathic scoliosis (AIS) is a structural, lateral, rotated curvature
of the spine that arises in otherwise healthy children at or around puberty.[1 ] It is the most common spinal disorder in adolescents, with a prevalence of 1 to
4%.[2 ] Early diagnosis of scoliosis allows timely treatment of the condition in its initial
stages, avoiding surgical treatment and deformity progression.[3 ] Consequently, scoliosis screening has been advocated for early detection of reversible
spinal curves before their progression.[4 ]
The screening of idiopathic scoliosis is widely discussed in the medical literature.[5 ] It involves different types of assessment methods, including visual inspection,
forward bending tests, scoliometer measurements, and individual Moiré topography,
which are straight forward and easily accessible.[6 ] The main findings of scoliosis on physical examination are asymmetry of the shoulders,
scapulae, pelvis, trunk, and ribcage.[3 ] The Adam's forward bend test is used to assess the presence of a hump and quantify
the lateral curvature; it is considered essential for the screening of scoliosis in
schools.[1 ]
[7 ]
[8 ] In Hong Kong, Netherlands and Singapore, countries with strong scoliosis screening
programs, the most frequent parameter are the Adam's forward bending test and the
measuring of trunk rotation using a scoliometer.[5 ]
[9 ]
[10 ]
Among all parameters on physical examination, shoulder imbalance has received a great
deal of attention among spine surgeons and researches alike.[11 ]
[12 ] The normal healthy population is considered to have level shoulders.[13 ] In any measured biological parameter, it is of prime importance that the variability
of what is classified as ‘normal’ is known, especially if surgery is planned to correct
that parameter from what is judged as ‘abnormal’ back to being ‘normal’.[14 ] In an attempt to define what is normal, Kuklo et al.[11 ] proposed shoulder balance as a lower than 1cm side-to-side difference between the
shoulders on clinical examination in adolescent idiopathic scoliosis patients.
The deficiencies of the traditional assessment methods for screening scoliosis remain
unresolved.[15 ] Regardless, an even more effective method is still crucial for reducing morbidities
associated with scoliosis. The present study aims to analyze the use of shoulder imbalance
as a parameter for scoliosis screening and its relationship with other parameters
of physical examination.
Methods
Type of Study
We performed a cross-sectional study to assess idiopathic scoliosis among students
aged 8 to 17 years in a public and a private school as well as in an athletic club.
The project was approved by the ethics committee (CAAE 07926919.5.0000.5128. The confidentiality
and privacy of the patients will be guaranteed throughout all stages of the study,
according to the principles of medical ethics.
Eligibility Criteria
Inclusion Criteria
Students at a public school, a private school, and members of an athletic club, aged
8 to 17 years, who accepted to participate willingly in the study and signed an informed
consent document were included in the present study. The participants' guardians also
needed to sign an informed consent form.
Exclusion Criteria
Previous spine surgery.
Previous diagnosis and treatment of scoliosis.
Diseases of the nervous system that compromise ambulation.
Understanding or cognitive problems.
Sample Size Calculation
The posthoc sample size calculation was done using the software R utilizing the Cohen
Kappa coefficient (IRR) with a concordance level of 5% and a confidence interval of
95%. Considering the shoulder imbalance parameter in frontal and posterior view and
the comparison of each examiner, the average number of participants was 74 (minimum
62 and maximum 87).
Study Locations
The locations were selected based on those that were the most representative of the
sample: a public municipal school and a private athletic club. The data was first
collected in the public school. Due to bureaucratic difficulties in the public school
and also to have a more heterogeneous sample, we extended the locations to the athletic
club and to a private school. In these two locations, we had a more controlled environment.
In the sport club, we started the survey with the boys, all basketball players, but
before we could enroll the female group in the analysis, we had to interrupt our study
because of the coronavirus disease 2019 (COVID-19) pandemic. We could not evaluate
the students at the private school for the same reason.
Selection and Training of Examiners
The examiners were selected aiming to include at least one examiner who was experienced
in the evaluation of individuals with adolescent idiopathic scoliosis (gold-standard
examiner), one orthopedist specialized in spinal surgery (inexperienced medical examiner),
and one non-medical examiner.
The examiners were trained for this activity and supervised by the main researcher
specialized in scoliosis. The team of examiners was composed of one orthopedist specialized
in spinal surgery (ExL), one surgical instrument technician (Ex1), and one orthopedist
in the 1st year of training in spinal surgery (Ex2).
Description of the Application
The children and adolescents were evaluated by the Scoliosis Screen mobile app, available
for iOS or Android (see electronic attachment: https://youtu.be/fs3aNbNf404 ). The application was developed at our university and is available in the Brazilian
Apple and Google stores. The evaluators were trained to use the software app and its
tutorials.
Analyzed Variables
The application assesses the following variables: head, shoulder, waist, ribcage,
and pelvic asymmetry in anterior and posterior view, the presence of kyphosis and
of a hump (Adam's test); and, finally, the measurement of upper, mid, and lower thoracic
scoliosis using the scoliometer (included in the sequence of evaluation utilizing
the smartphone accelerometer). The interobserver correlation of these variables between
the examiners was analyzed as well as the correlation of shoulder imbalance with the
Adam's test, scoliometer measure, and presence of a hump. The definition of shoulder
imbalance was visual, as seen in [Figs. 1 ] and [2 ].
Fig. 1 Shoulder asymmetry parameter in posterior view.
Fig. 2 Shoulder asymmetry parameter in anterior view.
Phases of the Evaluation
The examination of each subject was conducted by two alternate examiners in the following
manner: - Ex1–ExL; Ex1–Ex2. The subjects wore a short-sleeved T-shirt and shorts or
a jersey jacket. The examination was conducted in a reserved and quiet environment.
The subjects who presented with positive Adam's test, shoulder asymmetry, and a reading
superior to 2° on the scoliometer were invited to attend a free consultation with
the leading researcher. This clinical criterion was chosen to assess the use of shoulder
imbalance as a parameter for further investigation. The leading researcher receives
an email from the application whenever the alterations are detected and sends a letter
to the guardians inviting them to the specialized medical consultation.
Statistical Analysis
The data collected were initially entered into an Excel spreadsheet (Microsoft Corp.,
Redmond, WA, USA) spreadsheet and subsequently analyzed using the IBM SPSS Statistics
for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA) statistical package. The normality
of the continuous data was assessed using the Shapiro-Wilk test. The anthropometric
data were expressed as means, standard deviations, medians, and minimum and maximum
values. The changes observed on physical examination were presented in contingency
tables and expressed as absolute (n) and relative (%) frequencies. The agreement between
the researcher and the examiner was assessed with the Kappa test. The level of significance
was set at 5% (p <0.05) in all analyses.
Results
Anthropometric Data
The data were collected between August and December 2019. The number of participants
was 89. Of these, 18 were women and 71 were men. Two subjects were excluded from the
analysis, namely one subject who had already been diagnosed with neuromuscular scoliosis
and one with adolescent idiopathic scoliosis under medical monitoring. The mean age
of subjects from the public school was 11.3 years, the mean weight 39,0 Kg, the mean
height 1,5 meters, and a BMI (body mass index) of 17,9 ([Table 1 ]). In the athletic club, the mean age was 11.92 years, the mean weight 61,2 Kg, the
mean height 1,71 meters, and a mean BMI of 20,3 ([Table 2 ]).
Table 1
Mean
SD
Median
Minimum
Maximum
Age of the adolescent (years)
11.3
1.5
11.0
9.0
16.0
Weight (kg)
39.0
8.5
38.0
23.0
57.00
Height (cm)
150.0
10.0
152.0
130.0
163.0
BMI
17.9
2.2
17.5
14.3
21.6
Table 2
Mean
SD
Median
Minimum
Maximum
Age of the adolescent (years)
11.9
1.4
12.0
8.0
14.0
Weight (kg)
61.2
19.1
56.0
34.0
99.0
Height (cm)
171.0
13.0
171.0
147.0
191.0
BMI
20.3
4.2
19.8
15.5
30.3
Interobserver and Parameters Correlations
The ExL evaluated 54 individuals and referred 11 for re-assessment. Nine of these
had shoulder asymmetry and 2 had a curvature with a rotation>2°. The Ex1 evaluated
87 individuals and referred 24 for re-assessment. Twenty-four of these had shoulder
asymmetry, 5 had a hump, and 5 had changes in the scoliometer readings. The Ex2 evaluated
33 individuals and referred 11 of these, all with shoulder asymmetry. The ExL and
Ex1 achieved poor concordance in shoulder asymmetry in anterior and posterior view
and had slight agreement in posterior shoulder asymmetry, but poor concordance in
anterior shoulder imbalance. [Tables 3 ] and [4 ] show the analysis of the agreement on shoulder asymmetry in posterior and anterior
view between the examiners.
Table 3
ExL n (%)
Ex1 n (%)
Total
Kappa
P-value
Shoulder asymmetry (posterior)
9 (16.7)
12 (22.2)
21 (19.4)
0.0
1.00
Shoulder asymmetry (anterior)
14 (25.9)
13 (24.1)
27 (25.0)
0.16
0.23
Table 4
Ex1 n (%)
Ex2 n (%)
Total
Kappa
P-value
Shoulder asymmetry (posterior)
11 (33.3)
11 (33.3)
22 (33.3)
0.32
0.06
Shoulder asymmetry (anterior)
12 (36.4)
8 (24.2)
20 (30.3)
0.15
0.35
The parameters that were found to have significant statistic association with shoulder
asymmetry in posterior view, between ExL and Ex1, are waist and pelvis (posterior
and frontal), ribcage (frontal) and shoulder frontal asymmetry. Between Ex1 and Ex2,
the parameters that were found to have significant statistic association with shoulder
asymmetry in posterior view are scapular, waist (anterior and posterior), pelvis (anterior
and posterior), frontal ribcage, and shoulder anterior asymmetry and increased kyphosis.
[Tables 5 ] and [6 ] show the analysis of comparison between shoulder asymmetry and other changes in
physical examination.
Table 5
Shoulder asymmetry n (%)
P-value *
No
Yes
Head asymmetry (posterior)
0 (0.0)
0 (0.0)
na
Scapular asymmetry (posterior)
9 (10.3)
10 (47.6)
< 0.001
Waist asymmetry (posterior)
9 (10.3)
10 (47.6)
< 0.001
Pelvic asymmetry (posterior)
9 (10.3)
8 (38.1)
0.002
Increased kyphosis
7 (8.0)
3 (14.3)
0.37
Reduced kyphosis
9 (10.3)
4 (19.0)
0.27
Increased lordosis
16 (18.4)
5 (23.8)
0.57
Reduced lordosis
5 (5.7)
0 (0.0)
0.26
Head asymmetry (anterior)
0 (0.0)
1 (4.8)
0.04
Shoulder asymmetry (anterior)
15 (17.2)
12 (57.1)
< 0.001
Ribcage asymmetry (anterior)
4 (4.6)
4 (19.0)
0.02
Waist asymmetry (anterior)
11 (12.6)
9 (42.9)
0.001
Pelvic asymmetry (anterior)
10 (11.5)
9 (42.9)
0.001
Upper thoracic scoliometer
2 (2.3)
1 (4.8)
0.53
Mid-thoracic scoliometer
2 (2.3)
1 (4.8)
0.53
Lower thoracic scoliometer
3 (3.4)
1 (4.8)
0.77
Table 6
Shoulder asymmetry n (%)
P-value *
No
Yes
Head asymmetry (posterior)
0 (0.0)
1 (4.5)
0.15
Scapular asymmetry (posterior)
6 (13.6)
13 (59.1)
< 0.001
Waist asymmetry (posterior)
6 (13.6)
11 (50.0)
0.001
Pelvic asymmetry (posterior)
6 (13.6)
8 (36.4)
0.03
Increased kyphosis
5 (11.4)
7 (31.8)
0.04
Reduced kyphosis
2 (4.5)
0 (0.0)
0.31
Increased lordosis
9 (20.5)
7 (31.8)
0.31
Reduced lordosis
2 (4.5)
1 (4.5)
1.00
Presence of hump (anterior)
0 (0.0)
1 (4.5)
0.15
Head asymmetry (anterior)
0 (0.0)
1 (4.5)
0.15
Shoulder asymmetry (anterior)
5 (11.4)
15 (68.2)
< 0.001
Ribcage asymmetry (anterior)
4 (9.1)
10 (45.5)
0.001
Waist asymmetry (anterior)
10 (22.7)
15 (68.2)
< 0.001
Pelvic asymmetry (anterior)
11 (25.0)
13 (59.1)
0.007
[Table 7 ] shows the relation between the presence of hump and shoulder asymmetry in frontal
and posterior view. No significant statistical correlation between the parameters
was found.
Table 7
Presence of hump n (%)
P-value *
No
Yes
Shoulder asymmetry (posterior)
20 (19.6)
1 (16.7)
0.86
Shoulder asymmetry (frontal)
25 (24.5)
2 (33.3)
0.62
Discussion
Shoulder asymmetry is a common parameter used in the clinical evaluation of adolescent
idiopathic scoliosis. Our findings show that shoulder asymmetry has a poor-to-slight
interobserver correlation. We also did not find a strong association between the presence
of a hump and shoulder imbalance. However, the presence of a hump had a strong correlation
with trunk asymmetry—scapular (posterior), waist and pelvis (posterior and frontal),
ribcage (frontal), and shoulder frontal asymmetry.
The Adam's forward bend test is considered essential for the screening of scoliosis
in schools.[1 ]
[7 ]
[8 ] In Hong Kong, Netherlands and Singapore, countries with a strong scoliosis screening
program, the most frequent parameters are the Adam's forward bending test and the
measurement of trunk rotation using a scoliometer.[5 ]
[9 ]
[10 ] However, Fong et al.[5 ] demonstrated that screening performed using only Adam's forward bend test is insufficient
and results in a high rate of false positives. It is necessary to add other parameters
to increase the quality of scoliosis screening. The combination of the scoliometer,
Adam's forward bend test, and Moiré topography has a sensitivity and specificity close
to 94% and 99%, respectively.[15 ] Even so, Moiré topography is not a widely used tool, and its application is restricted
to a few centers.
Our study aims to evaluate the other physical parameters for scoliosis screening.
We had a greater number of pupils with shoulder asymmetry than with positive result
in the Adam's test. This parameter needs an outpatient clinic's assessment to be validated.
The subjects still need the next step of the evaluation with a specialized medical
consultation and radiological images.
An important point is the definition of what constitutes shoulder asymmetry. Kuklo
et al.[11 ] proposed shoulder symmetry as a side-to-side difference of less than 1cm between
the shoulders on clinical examination in adolescent idiopathic scoliosis patients.
However, the study was done in patients with the diagnosis of scoliosis. Gardner et
al.[14 ] demonstrated that a degree of asymmetry in shoulder and torso is also seen in a
group of children and adolescents who do not have scoliosis. Akel et al.[13 ] demonstrated that healthy adolescents may have a difference of up to 27mm between
their shoulders without a change in their body image perception.
The difficulty in defining what is, in fact, shoulder asymmetry may be the cause of
the low rate of interobserver concordance in our study. In our analysis, shoulder
asymmetry was based on a visual observation of the patient comparing with an image
of the application ([Figs. 1 ] and [2 ]). The definition of shoulder asymmetry was subjective. Because of that, we found
that an improvement of our application was needed to have a better concordance between
the observers.
We did not find a significant difference in the prevalence of shoulder asymmetry between
the school group and the athletic club group. The athletes analyzed in our study were
all basketball players. Basketball is a sport that involves symmetrical effect on
muscle structure. However, when first starting in the sport, the predominant use of
the dominant side could lead to hypertrophy of the muscles involved. Despite that,
our study did not show any difference between the groups.
The difficulty of data collection was one of the study's limitations. There was also
greater difficulty because of COVID-19. Since this is a screening study, our sample
is still not sufficiently representative, and another study will be required for further
assessment and interpretation of the data.
The quality of the comparative analysis will improve once we obtain the data from
the paired comparison between the leading examiner and other non-medical examiners
(considering that the data collected so far were provided by only one non-medical
examiner). It is important to analyze the results of the physical examination and
X-ray after referral of individuals in whom the application showed alterations to
a specialist. We will, then, be able to validate or not the use of shoulder imbalance
as a useful parameter in the screening method.
Conclusion
In conclusion, screening for idiopathic scoliosis is a public health concern. Our
preliminary study showed a poor correlation between shoulder asymmetry, Adam's forward
bending test, and measurement of trunk rotation using a scoliometer. Therefore, the
use of shoulder imbalance might not be useful for scoliosis screening. However, this
is a preliminary study, and the referred subjects still need the next step of the
evaluation with a specialized medical consultation and radiological images.
