How We Do It Vivian K. Harlin, MD Contributing Editor
RESULTS OF SCHOOL SCREENING FOR SCOLIOSIS IN THE SAN JUAN UNIFIED SCHOOL DISTRICT, SACRAMENTO,CALIFORNIA Karen D. Benson, MLA; Betty Wade, BA, PHN; Daniel R. Benson, MD
During the school year 1975-1976, 7,815 sixth-, seventh-, and eighthgrade students were screened for scoliosis in the San Juan Unified School District, Sacramento, California. The initial screening was conducted by the district’s school nurses and physical education instructors. An orthopedic surgeon, familiar with the diagnosis and treatment of spinal deformity, rescreened the pupils. Those students suspected of having scoliosis were referred to their private medical doctor for a standing x-ray and further evaluation. The purpose of school screening for scoliosis is that early detection and treatment can often prevent major, expensive, and sometimes hazardous surgery. Methods The San Juan Unified School District used the following procedure to screen its students. Initially, a letter describing scoliosis and the screening method was sent home to the parents. A joint class of school nurses and physical educa-
tion teachers viewed a scoliosisscreening movie. This was followed by instruction in the examining techniques by an orthopedic surgeon. The techniques involved the standard forward bending test and determination of shoulder height, waistline deformities, and scapular prominence. At their home schools, nurses and physical education teachers examined their students during physical education classes. Girls and boys were screened separately and were examined bare-backed or in a swimming suit. Students who appeared to have any type of spinal deformity were rescreened by an orthopedic surgeon at a later date. If the orthopedist concurred that a possible curve was present, a letter was sent home to the parents. The letter notified parents of the potential problem and urged them to take their child either to their private medical doctor or to one of several local clinics for a standing x-ray and further evaluation. The school nurses were responsible for all follow-up on these students. OCTOBER 1977
Results Students in the eleven intermediate schools of the San Juan Unified School District were screened. The sixth-grade classes from seven elementary schools were also seen. Of the 7,815 students originally screened by the school nurses and physical education teachers, 1,328 or 17% were reexamined by the orthopedist. Two hundred twenty-one students or 2.82% of the original total seen were referred to their private medical doctor for x-ray and further evaluation. Radiographic diagnosis of scoliosis was determined in 121 students, or 1.5Vo of the 7,815. Eighteen students had negative findings on medical examination. No follow-up was reported for 77 pupils, and five students had moved. Discussion
The need for early detection is essential. Spinal curves commonly occur in adolescence and may progress during the time of rapid growth. If spinal curvature is discovered early and properly braced throughout this growth period, then deformity is avoided and surgery prevented. Thus, the need for annual school screening for scoliosis during the years of greatest growth is apparent. Routine school examination for scoliosis is being conducted in many areas of the United States.I4 Two notable examples are Minnesota and Delaware. School screening has occurred throughout2 the state of Minnesota since 1973. In Delaware, because of a state-wide school screening program, which has been in effect for more than ten years, virtually no children require surgical correction and fusion for idiopathic 3 scoliosis. Yearly routine examination of adolescents for scoliosis apparently provides an efficient safeguard from further deformity and possible surgery. Close follow-up by the school nurses after initial referral is impor-
THE JOURNAL OF SCHOOL HEALTH
483
tant in order to determine that appropriate action has been taken and care received. The need for community understanding of scoliosis and the history of treatment are essential to the success of the school screening program. Follow-up shows that of the 221 referred, 139 were evaluated by a physician. Of that 139, 87% were diagnosed as having a spinal deformity requiring treatment. Treatment consisted of Milwaukee bracing with exercises, exercises only, or interval observations by a physician. Few parents appeared to comprehend fully the progressive nature of scoliosis and its hazards to health. After receiving a referral letter, parents may procrastinate about treatment for their child out of fear that something may be wrong. The interim between the school referral and seeing a physician can be an anxious time because the diagnosis is unknown. Fuller understanding and knowledge about this condition should aid complete follow-up for every child. Another advantage of an educated community is the benefit to those students required to wear a brace during their adolescent years. The Milwaukee brace is bulky and not easily hidden by clothing. Many students are especially sensitive to stares and comments by strangers or schoolmates. An enlightened school community would provide a more understanding atmosphere for those wearing Milwaukee braces. Summary Annual routine school examination for scoliosis has been established in the San Juan Unified School District. Additionally, several parochial schools and other schools in the county or nearby towns have expressed interest in such a program. A rapid, effective method, taking no more than 30 seconds per child, has been used to detect spinal curvature. The pro404
gram is beneficial for those identified with scoliosis, because early detection, followed by proper treatment, can prevent major surgery. The need for careful school nurse follow-up must be emphasized. A standing x-ray and evaluation by a qualified physician are imperative. If scoliosis is diagnosed, the school nurse can be a very effective contact in assisting the students by discussing exercise or brace care and by providing encouragement and general supportive help. REFERENCES 1. Brooks HC, Azen SP, Gerber E, et al: Scoliosis - A prospective epidemiological study. J Bone Joint Surg 57-A:968, 1975. 2. Lonstein JE, Winter RB, Moe JH, et al:
School screening for the early detection of spine deformities. Minn Med 5951, 1976. 3. Shands AR Jr. Eisberg HB: The incidence of scoliosis in the state of Delaware. J Bone Joint Sug 37-A:1243, 1955. 4. Winter RB, Moe JH: A plea for the routine school examination for spinal deformity. Minn Med 57:419, 1974.
Karen D. Benson, MLA, 2900 Laurel Drive, Sacramento, California 95825. Betty Wade, BA, PHN, San Juan Unified School District, 4300 El Camino Avenue, Sacramento, California 95821. Daniel R . Benson, MD, b Assktant Professor of Orthopaedics, University of California, Davis, 4301 X Street, Sacramento, California 9581 7 (corresponding author).
PREPARING A DIRECTORY OF COMMUNITY HEALTH SERVICES Stephen R. Sroka, MEd
Do you know what health services are available in your community, and where they are located? If you were asked where to obtain an eye examination or a free and confidential VD examination, could you give accurate information? If you cannot, perhaps you need a directory of health services. If you decide you need a directory and would like to produce one, be sure that a directory is not already available. Often a call to the Public Health and Welfare Department can clarify this situation. In producing a directory for the near west side of Cleveland, the following factors were considered: 1. Who will be your volunteers to gather data, write the directory, and provide secretarial help? Students from junior high school health
THE JOURNAL OF SCHOOL HEALTH
OCTOBER 1977
classes were used in this particular project. A neighborhood outreach worker also was recruited to help. Other possibilities would be other teachers, college students, high school students, parents, and concerned citizens. 2. If working in a school, is there a convenient meeting place available? If not, or if you decide to meet elsewhere, there are usually many civic agencies that will allow you to use their facilities for a meeting place. We used a neighborhood Lutheran Center. 3. When do you plan to work on the directory-after school, on weekends, or during summer vacations? You must consider the hours that the volunteers are available and when the health agencies would be open for interviews as well as your
RESULTS OF SCHOOL SCREENING FOR SCOLIOSIS IN THE SAN JUAN UNIFIED SCHOOL DISTRICT, SACRAMENTO,CALIFORNIA Karen D. Benson, MLA; Betty Wade, BA, PHN; Daniel R. Benson, MD
During the school year 1975-1976, 7,815 sixth-, seventh-, and eighthgrade students were screened for scoliosis in the San Juan Unified School District, Sacramento, California. The initial screening was conducted by the district’s school nurses and physical education instructors. An orthopedic surgeon, familiar with the diagnosis and treatment of spinal deformity, rescreened the pupils. Those students suspected of having scoliosis were referred to their private medical doctor for a standing x-ray and further evaluation. The purpose of school screening for scoliosis is that early detection and treatment can often prevent major, expensive, and sometimes hazardous surgery. Methods The San Juan Unified School District used the following procedure to screen its students. Initially, a letter describing scoliosis and the screening method was sent home to the parents. A joint class of school nurses and physical educa-
tion teachers viewed a scoliosisscreening movie. This was followed by instruction in the examining techniques by an orthopedic surgeon. The techniques involved the standard forward bending test and determination of shoulder height, waistline deformities, and scapular prominence. At their home schools, nurses and physical education teachers examined their students during physical education classes. Girls and boys were screened separately and were examined bare-backed or in a swimming suit. Students who appeared to have any type of spinal deformity were rescreened by an orthopedic surgeon at a later date. If the orthopedist concurred that a possible curve was present, a letter was sent home to the parents. The letter notified parents of the potential problem and urged them to take their child either to their private medical doctor or to one of several local clinics for a standing x-ray and further evaluation. The school nurses were responsible for all follow-up on these students. OCTOBER 1977
Results Students in the eleven intermediate schools of the San Juan Unified School District were screened. The sixth-grade classes from seven elementary schools were also seen. Of the 7,815 students originally screened by the school nurses and physical education teachers, 1,328 or 17% were reexamined by the orthopedist. Two hundred twenty-one students or 2.82% of the original total seen were referred to their private medical doctor for x-ray and further evaluation. Radiographic diagnosis of scoliosis was determined in 121 students, or 1.5Vo of the 7,815. Eighteen students had negative findings on medical examination. No follow-up was reported for 77 pupils, and five students had moved. Discussion
The need for early detection is essential. Spinal curves commonly occur in adolescence and may progress during the time of rapid growth. If spinal curvature is discovered early and properly braced throughout this growth period, then deformity is avoided and surgery prevented. Thus, the need for annual school screening for scoliosis during the years of greatest growth is apparent. Routine school examination for scoliosis is being conducted in many areas of the United States.I4 Two notable examples are Minnesota and Delaware. School screening has occurred throughout2 the state of Minnesota since 1973. In Delaware, because of a state-wide school screening program, which has been in effect for more than ten years, virtually no children require surgical correction and fusion for idiopathic 3 scoliosis. Yearly routine examination of adolescents for scoliosis apparently provides an efficient safeguard from further deformity and possible surgery. Close follow-up by the school nurses after initial referral is impor-
THE JOURNAL OF SCHOOL HEALTH
483
tant in order to determine that appropriate action has been taken and care received. The need for community understanding of scoliosis and the history of treatment are essential to the success of the school screening program. Follow-up shows that of the 221 referred, 139 were evaluated by a physician. Of that 139, 87% were diagnosed as having a spinal deformity requiring treatment. Treatment consisted of Milwaukee bracing with exercises, exercises only, or interval observations by a physician. Few parents appeared to comprehend fully the progressive nature of scoliosis and its hazards to health. After receiving a referral letter, parents may procrastinate about treatment for their child out of fear that something may be wrong. The interim between the school referral and seeing a physician can be an anxious time because the diagnosis is unknown. Fuller understanding and knowledge about this condition should aid complete follow-up for every child. Another advantage of an educated community is the benefit to those students required to wear a brace during their adolescent years. The Milwaukee brace is bulky and not easily hidden by clothing. Many students are especially sensitive to stares and comments by strangers or schoolmates. An enlightened school community would provide a more understanding atmosphere for those wearing Milwaukee braces. Summary Annual routine school examination for scoliosis has been established in the San Juan Unified School District. Additionally, several parochial schools and other schools in the county or nearby towns have expressed interest in such a program. A rapid, effective method, taking no more than 30 seconds per child, has been used to detect spinal curvature. The pro404
gram is beneficial for those identified with scoliosis, because early detection, followed by proper treatment, can prevent major surgery. The need for careful school nurse follow-up must be emphasized. A standing x-ray and evaluation by a qualified physician are imperative. If scoliosis is diagnosed, the school nurse can be a very effective contact in assisting the students by discussing exercise or brace care and by providing encouragement and general supportive help. REFERENCES 1. Brooks HC, Azen SP, Gerber E, et al: Scoliosis - A prospective epidemiological study. J Bone Joint Surg 57-A:968, 1975. 2. Lonstein JE, Winter RB, Moe JH, et al:
School screening for the early detection of spine deformities. Minn Med 5951, 1976. 3. Shands AR Jr. Eisberg HB: The incidence of scoliosis in the state of Delaware. J Bone Joint Sug 37-A:1243, 1955. 4. Winter RB, Moe JH: A plea for the routine school examination for spinal deformity. Minn Med 57:419, 1974.
Karen D. Benson, MLA, 2900 Laurel Drive, Sacramento, California 95825. Betty Wade, BA, PHN, San Juan Unified School District, 4300 El Camino Avenue, Sacramento, California 95821. Daniel R . Benson, MD, b Assktant Professor of Orthopaedics, University of California, Davis, 4301 X Street, Sacramento, California 9581 7 (corresponding author).
PREPARING A DIRECTORY OF COMMUNITY HEALTH SERVICES Stephen R. Sroka, MEd
Do you know what health services are available in your community, and where they are located? If you were asked where to obtain an eye examination or a free and confidential VD examination, could you give accurate information? If you cannot, perhaps you need a directory of health services. If you decide you need a directory and would like to produce one, be sure that a directory is not already available. Often a call to the Public Health and Welfare Department can clarify this situation. In producing a directory for the near west side of Cleveland, the following factors were considered: 1. Who will be your volunteers to gather data, write the directory, and provide secretarial help? Students from junior high school health
THE JOURNAL OF SCHOOL HEALTH
OCTOBER 1977
classes were used in this particular project. A neighborhood outreach worker also was recruited to help. Other possibilities would be other teachers, college students, high school students, parents, and concerned citizens. 2. If working in a school, is there a convenient meeting place available? If not, or if you decide to meet elsewhere, there are usually many civic agencies that will allow you to use their facilities for a meeting place. We used a neighborhood Lutheran Center. 3. When do you plan to work on the directory-after school, on weekends, or during summer vacations? You must consider the hours that the volunteers are available and when the health agencies would be open for interviews as well as your
