After being diagnosed with adolescent idiopathic scoliosis and undergoing bracing while my dad underwent spinal fusion surgery, I gained a great interest in scoliosis. Surrounded by myths and misguided information I wanted to research the subject myself. Because adolescent idiopathic scoliosis is still a mystery in its cause treatments play a very important part in dealing with the condition. Much of my research was devoted to finding and analyzing what scoliosis was, what treatments were available, and what were the most beneficial methods offered today.
Scoliosis is viewed from both extremes; from harmless to horribly deforming. Though it can be seen in patients at both extremes, most of those diagnosed with scoliosis are not in serious danger of gross deformity like the images of the hunchback of Notre Dame, but should be watched for progression and symptoms of related complications. Under the right circumstances scoliosis can be handicapping, but unless the condition has been allowed to progress it is usually treatable. Scoliosis is not curable, but curvatures can be partially corrected and associated pain can be alleviated.
The term scoliosis actually refers to an abnormal curvature of the spine, a lateral (side-to-side) and/or sagittal (rotating) curvature. A normal spine has some curvature already to it, known as the thoracic (upper back) and lumbar (lower back) curves. There are numerous branches of scoliosis that are grouped by identified cause. Such groups are idiopathic, congenital, neuromuscular, neurofibromatosis, mesenchymal disorders, trauma , and those resulting from "poor posture, differences in leg length, muscle spasms, or, rarely, a tumor or growth on the spine."
Adolescent idiopathic scoliosis is a specific type of scoliosis, sometimes referred to as AIS, which occurs in adolescents and is idiopathic, meaning that its cause is unknown. Idiopathic scoliosis can be further classified as structural and nonstructural. Three-dimensional curvatures are identified as structural while lateral curves are considered nonstructural. A figure of 2-3% has been noted of adolescents who have scoliosis and 80% of those are idiopathic. Because we do not know what causes this condition we cannot predict who will and who will not develop scoliosis in adolescence, though there are statistics which show there is 3.6 to 1 ratio of girls to boys who have been identified and a 10 to1 ratio of girls to boys that have angles more than or equal to 30 degrees. AIS is especially unpredictable due to the period in which it develops. In adolescence large growth spurts occur and a child with a normal back may develop a large curve during this period. This factor plays an important part in treatment as will be discussed later.
Due to the unpredictability of idiopathic scoliosis in adolescence there is no one treatment. An explanation and analysis of the treatments will be discussed. Some of the information presented will be from personal experience and second hand experience from a related patient. This information is above and beyond scientific definitions and may bias the analysis of the treatments, but the goal is to introduce what adolescent idiopathic scoliosis is, who gets the condition, and how the condition is diagnosed with an emphasis on what treatments are available and which are appropriate. It is important to include that treatment of scoliosis does not mean a cure and that a patient’s attitude, lifestyle, type and magnitude of curvature, age, and family history are crucial to determining an appropriate treatment for each patient.
The primary evaluations used to identify a patient with scoliosis include a visual examination which uses cues such as balance at the hips and shoulders and an overall symmetry. By tracing the spine while the patient leans forward, known as the Adams forward-bending test a curvature can be detected, but a tool known as the Scoliometer is also used. This tool acts as a level from one point of the back to another. Such a screening must be thorough in examining the back from many angles to ensure detection of a lateral or sagittal curvature. Scoliosis can make the spine appear in a "C" shape and sometimes in that of a "S" that corrects itself at the cervical (neck) and lower lumbar (lower back) vertebrae.
Primary examination is a very crucial step in detecting scoliosis as soon as possible, but it is not considered the most dependable method. Currently there is a debate, for example, on the effectiveness of school screenings on finding those with scoliosis. This form of primary evaluation performed by trained nurses was found to have a "positive predictive value of…8%." These types of screenings have very low rate of identifying scoliosis; therefore, parents should be trained and encouraged to watch their children carefully for any back prominence before and during rapid growth. Adolescent idiopathic scoliosis is also difficult to diagnose due to its lack of symptoms including back pain (pain is usually related to problems of the nerve near the spine, stress, weight, and arthritis). These problems usually do not manifest themselves until after adolescence. The instability of growth patterns during adolescence and the relationship of scoliosis to growth sometimes results in an unexpected presence that can be missed by casual evaluation.
Once a reasonable suspicion has been noted from a primary evaluation further examinations and x-rays are taken so that the Cobb angles may be measured. Cobb angles are a form of measurement of the back’s curvatures which are read on a roentgenogram using a protractor and a straight edge. These measurements differ from doctor to doctor, but there is a 95% confidence that the results only differ from 3-5%.
A patient is diagnosed by the magnitude of the curvature and the angle of trunk rotation (ATR). A curvature of 11 degrees or more is considered scoliosis, but unless there are other extenuating circumstances it is not treated until the curve reaches 30 degrees and/or has an ATR of 7 degrees. Such circumstances can be family history that reflects the same type of curve in similar time bands, rapid and continuous progression, negative effects on appearance and self-esteem of the patient, and related health problems present or foreseen as a result of the scoliosis. There are many elements used in determining the advantages and disadvantages of treatment and if there is a need for such action. One of these elements is the probability of self-correction. Even those patients with a 20 degree curve have been known to improve on their own, but usually 1 in 5 patients grow worse. Three patients in 1,000 worsen to a point where treatment is necessary.
Family history needs to be recognized as a key to determining the probability of progression of a curve and the physical and emotional effects on adulthood life. It is especially important when curvatures are of the same type and magnitude in similar time frames. Sometimes this similarity can be the deciding factor in a borderline patient on whether they should be treated or observed. Studies have shown a strong correlation between patients with scoliosis and a family history for scoliosis. It is estimated that an adolescent of two parents who have the condition has 50 times the chance of needing treatment than that of unaffected parents. While it is still being researched, there have been some reports on a connection between defects in the fibrillin gene that are hereditary. In a study of 25 families, 4 of 23 individuals with AIS had an abnormality in the production of fibrillin. Skeletal maturity is also an important factor in determining treatment of AIS. A patient whose skeletal structure has begun to solidify in comparison to its flexibility in childhood will be less responsive to bracing than one whose skeletal structure is still in the process of maturation. This is due to the fact that bracing attempts to halt abnormal growth and guide the spine during growth. A patient who has skeletal maturity will not grow much more, so the guidance of bracing during growth will be ineffective and therefore inappropriate, with surgery as a better option.
In addition to skeletal maturity, sexual maturity in girls is also measured. On a scale of 0-5, the Risser Scale marks the level of maturity based on the menarche, or first menstrual cycle. Premenarchal is noted by a 0 and a 3 notates up to 6 months postmenarchal. This measurement is another determination of maturity and the probability of growth. A girl with a measure of 4 of the Risser Scale will have less growth than a girl noted with a 0. Attitude and self-image are probably the most important in determining which treatment to prescribe. Teenagers find it difficult to wear the brace because it is bulky and hard to maneuver in, but without treatment sometimes the visual deformities of scoliosis can damage a teenager’s self-esteem. Consequences of not undergoing treatment must be weighed carefully with how much it will affect the patient if treatment is undergone. Doctors and parents must also be aware that if they do decide to proceed with treatment that it must have some approval of the patient, for example, many teenagers do not wear their braces as instructed. By not wearing the brace as instructed they can be influencing the effectiveness of the method.
Lifestyle may alter the decision too of which treatment to follow. An active teenager may not wish to be constricted by a brace, but may have a curve that must be halted. Such a teenager may opt for treatments such as electric shock or surgery that has a quicker, more thorough recovery than an extensive brace treatment. Effects of surgery are not yet completely understood, however, and it is debated if it limits normal vertical growth and/or flexibility. A ballerina for example may want to maintain full flexibility and so decide to undergo another treatment rather than surgery. A patient’s activities are extremely pertinent to how their scoliosis should be treated.
One last element of deciding on a treatment is financial burden. Because treating adolescent idiopathic scoliosis is usually a preventive measure many insurance companies will only pay part of the overall cost. This problem is mostly encountered in bracing and other noninvasive procedures, but it is enough of a factor to be noted. As a preventative measure in most teenagers, treating scoliosis is often neglected because it is thought not to be cost-effective although treatment may prevent other problems in the future. Treatment is categorized either as invasive or noninvasive. The main goal of treating AIS is to monitor progression and prevent further curvature, or in more serious curves to operate. The noninvasive treatments act to prevent further curvature during the growing period of adolescence. The first level of treatment is observation. It is the most basic form of noninvasive treatment. If this treatment is employed the patient receives regular examinations from a doctor who watches for any changes, either negative or positive. This method is used commonly for curves that do not seem to be threatening; ones that do not seem to progress or cause cosmetic or health related complaints. For those curves which have one or more discerning factors it is advised to proceed with an additional form of treatment. Also, during observation if the doctor finds it necessary he/she can prescribe further treatment.
Another low impact treatment on the daily life of a patient is exercises and/or specific physical therapy. Some of this therapy includes proper posture and breathing training. Most of it is concentrated on muscle control and flexibility. One form of these exercises is the practice of yoga. Currently, there is a lack of study if exercise alone, or in combination with other treatments, is effective. Most exercise studies have a lack of controls so their efficacy has not been determined. Though exercise is healthy and helpful in maintaining weight and muscle tone "by itself, exercise does not appear to straighten existing curves or prevent progression."
Electrostimulation is another method which shows little benefit. A major study done in 1994 showed that "progression occurred in 70% of patients who had used [electrostimulation]." Also known as LESS, or lateral electrical surface stimulation, electrostimulation is still controversial. It does have a higher compliance rate than bracing due to its application during the night and less discomfort (though some complained of "sleeplessness and irritability" ). A study showed 50% of the patients complied well and only 5% complied poorly. At first the rate of progression in early studies remained very low at 0%-5%, but later studies revealed 18%-56% had progressed 10 degrees or more. The method of biofeedback has also been used to treat scoliosis with the thought that by gaining control of muscles one could self-correct curvature of the spine. It functions by sounding an alarm when the patient exhibits poor posture by information sent to a computer from sensors. No long-term studies were performed so the overall effectiveness of the biofeedback method in treating scoliosis is not known. Short-term effects on early trials, however, did have some reduction in curvature. This probably represents only the small group of patients with scoliosis hypothesized to have been caused by poor posture and related factors.
The most common of all the treatments is bracing. Its goal of stabilizing the curve best meets the needs of the majority of patients with scoliosis. Part of its effectiveness is due to its compatibility with the body of a teenager. Working with the growing body it guides the spine into a straighter: more stable position. With the use of a brace an improved curve is not expected; rather, a holding position is desired until most of the growing is completed. Bracing is not a cure for scoliosis, but a measure to halt its progression. Progression, however, is not always held. Progression sometimes occurs later in adulthood for unknown reasons when in adolescence it was immobilized. Though there are some questions "about its efficacy [,] bracing is the only nonoperative method to alter the natural progression of curvature." Though the majority of the time bracing seems effective, with a 70%-80% success rate of halting and/or improving curvatures, it has its drawbacks. Made of plastic, Velcro straps, and metal fasteners most braces are uncomfortable. They are custom fitted from a plaster of paris mold taken from each individual patient. The heavy plastic is padded with a thin layer of foam and worn snuggly to the body. Holes are added to the plastic to allow the skin to breathe, but a lot of body heat is retained by the brace. Other complaints include limited movement, tears to clothing, bulkiness, and discomfort from the constant upright position. It is also known to reduce pulmonary capacity (lung capacity). Baggy clothing can sometimes mask the unnatural shape of the brace, but this has a great effect on the self-esteem and peer relationships of the adolescent patients. A negative attitude towards treatment has demonstrated a higher noncompliance rate where "patients actually wore their braces 65% of the recommended time." In efforts to increase compliance doctors are in search of the minimal hours in which the brace should be worn and still be beneficial. "In the past, patients have been instructed to wear the braces 23 hours per day…16 hours per day may produce the same benefits." There are several styles of braces available to tailor to the patients’ correcting needs. The most commonly used are the Milwaukee brace (cervico-thoraco-lumbo-sacral-orthosis) and the TLSOs (thoraco-lumbo-sacral-orthosis). The Milwaukee brace, originating in the 1940’s, uses straps, plastic, pads and a metal neck hold to concentrate on the upper thoracic curves. This is why it also immobilizes the neck (cervico). The TLSOs are the most commonly used and they are usually referred to as low-profile because they rest under the arms of the patient. Smooth plastic contoured to the patient’s body also help hide the apparatus under clothing. Their concentration lies mostly in the lower thoracic and nearly sacral regions. There are many types of TLSO’s including those with names such as the Boston brace, the Miami brace, the Wilmington jacket, and the Rosenberger orthosis. While TLSO’s may have improved compliance due to their appearance and therefore perhaps better improvement and smaller progression rates, the Milwaukee brace theoretically provides better treatment of thoracic curves. Both use principles of biomechanics to push at points that will correct and/or hold curves. The Charleston Bending Brace, developed in 1979 used the theory that by overcorrecting a curve the back would compensate, therefore correcting itself. Worn only 8 hours during the night it was hoped to be a more rapid and effective type of brace with minimal negative effects. Long term effects however have not yet been studied, but it is of great interest to the medical community if this partial-day plan will have the same benefits of that of the full day.
Surgery is usually considered the last option for treatment of scoliosis. Because most curves in adolescents are not of a great enough significance for immediate consideration of surgery bracing is usually first attempted. If bracing fails to halt the progression of the curve then surgery is offered as an alternative method. "Unlike bracing, which is intended merely to stop curve progression, surgical intervention may improve the curve." Surgery is used to treat scoliosis for four basic reasons: "(1) to prevent further progression of the curve (2) to control the curve when brace treatment has failed (3) to improve undesired cosmetic appearance and (4) for reasons of discomfort or postural fatigue." Cases in adolescents that involve curvatures of 50 degrees or more are uncommon, but it is in this case surgical intervention may be listed as a primary treatment. Bracing will not significantly improve a curvature of this degree and without action the curve will cause problems in adulthood. This is an example when surgery is necessary. Surgery is like bracing in that its goal is to maintain the curvature, but in surgery it forces the curve into a straighter alignment and then holds the spine in place. Surgical intervention is especially important in structural scoliosis where lateral and sagittal corrections need to be made. In addition to actually correcting the curvature, surgery is beneficial in providing a short term and effective treatment. This has a different effect on a patient than years of wearing a brace and in "one study [it was] found that women treated in adolescence with posterior spinal fusion claimed to have better sexual adjustment, less impaired self-esteem and better body image than women treated with bracing." It is probable that most of this study is based on correlation rather than an experimental vs. control group setting so its data are questionable, but some of the results are consistent with complaints of patients undergoing brace treatment that are lacking in those undergoing surgery. Complete long term effects and results have not been thoroughly tested for the newer surgical methods so we are unsure of all the possible drawbacks to these methods. As with any invasive procedure there are possibilities of complications including allergic reactions and infection. Surgery of the spine can have complication rates of nearly 10%. Dangers of spinal surgery include serious consequences from damage to the spinal cord and its surrounding vertebrae. The use of metal hooks and bolts also increase the chance of body rejection and have their own set of complications including dislodgment of the rods and hooks. In young adults it is also important that these procedures allow for some growth and retention of flexibility without much loss to the correction. Statistics and results of these surgeries on adolescents have not been fully examined for long term results. The surgeries used to treat scoliosis are orthorodesic procedures, ones that fuse the vertebrae to orthotic appliances. They are performed from one or two ways of entry, posteriorly (through the back) and anteriorly (through the chest cavity). The first standard of these types of surgeries was the Harrington Procedure which employs one or more steel rods that extend from one end of the curve to the other. This rod is held in place with hooks secured to the vertebrae with pegs. This procedure has been compared to "changing a tire, the steel rod is jacked up and then locked into place to support the spine securely." It does not correct three-dimensional curvatures and recovery involves a full body cast for three to six months. The next method to be developed was the Luque system which used wires instead of hooks and pegs to attach the rod to the vertebrae. Later the Cotrel-Dubousset method allowed for correction of structural curvatures as well as lateral ones. This procedure uses parallel rods and multiple hooks to create a better stability. This surgery is often longer, has a higher risk of imbalance, and involves more blood loss than the Harrington model, but it does not create the flat back syndrome. More recent procedures include an anterior approach such as that in the Zielke model. This type of procedure concentrates on a small correction site with a rod screwed into the vertebrae by compression. The Texas Scottish Rite Hospital system uses the same principles as the Zielke model, but with a larger rod and nuts and bolts arrangement. The Isola technique which uses a flexible rod and multiple hooks like that of the Texas Scottish Rite and the Zielke model, but it uses drop set screws.
It is important to remember when deciding what form of treatment to apply to a patient that his his/her needs extended beyond the physical treatment to also include consideration for emotional factors. Support groups can be suggested outside the doctor’s office for patients and their families. These groups can also be a good source of additional information and help dispel common fears about scoliosis.
In analysis of the different techniques in treating AIS it is difficult to weigh their advantages and disadvantages due to their wide variation and in most cases, lack of complete long-term study. In choosing an appropriate treatment for a condition which is not completely understood, compliance is especially important. This pertains to bracing which has a lower compliance rate vs. a method like electrostimulation that has a higher compliance rate. Although the electrostimulation has a higher compliance rate it does not necessarily mean it is more effective than bracing; studies in progress are analyzing if fewer hours of bracing is as effective as full-day so that its compliance rate would increase with the same efficacy. Surgery is an appropriate option for patients with AIS when bracing fails or is ineffective and the severity of the curve requires further treatment. Still, all treatments need to be prescribed according to the patient’s needs by the type and magnitude of his/her curve, age, gender, and skeletal maturity, but their treatment should be specialized for their personality also. Scoliosis can be treated by a range of treatments and although some are considered less effective than others it sometimes remains on an individual basis.
Endnotes
Richardson, Michael L., M.D. "Scoliosis." Rev. 6 Aug 1994.
Well-Connected. Scoliosis. Report #68. 1996 Nidus Information Services, Inc., 31 Aug 1996.
Ibid.
Farley, Dixie. "Correcting the curved spine of scoliosis." FDA Consumer. Pg. 1.
Ibid.
Woolf, Steven H. M.D., M.P.H. US Preventive Services Task Force. 47. Screening for Adolescent Idiopathic Scoliosis. Pg. 2
Ibid.
Basset, George S., M.D. and Skaggs, David L., M.D. "Adolescent Idiopathic Scoliosis: An Update." American Family Physician. Pgs. 2327-2334.
Ibid.
Well-Connected. Scoliosis. Report #68.
Farley, Dixie. FDA Consumer.
Lonstein, John E. "Adolescent idiopathic scoliosis." Review article. The Lancet. 19 Nov 1994. Pgs. 1407-1412.
Clark, Stephanie. "New twists in scoliosis research." News. The Lancet. 9 April 1994. Pg. 910.
Basset, George S., M.D. and Skaggs, David L., M.D.
Woolf, Steven H.
Well-Connected.
Ibid.
Well-Connected.
US Preventive Services Task Force. Review article. "Screening for Adolescent idiopathic Scoliosis: Policy Statement." JAMA. 26 May 1993.
Ibid.
Well-Connected.
Farley, Dixie.
Archives of Pediatrics and Adolescent Medicine. "Nonoperative Treatment of Scoliosis and Kyphosis." June 1994.
The Backletter. "Bracing Effective in Slowing Spinal Curvature." Vol. 9. No. 2.
Basset, George S., M.D. and Skaggs, David L, M.D.
Ibid.
Archives of Pediatrics and Adolescent Medicine
Farley, Dixie
Ibid.
Meade, Kevin P., Ph.D. "Orthotic treatment from idiopathic scoliosis: current concepts." BioConcepts Inc.
Ibid.
The Spinal Connection. "Bracing for Adolescent Idiopathic Scoliosis."
Basset, George S., M.D. and Skaggs, David L, M.D.
Surgical Treatment of Scoliosis. "What is scoliosis?" National Scoliosis Foundation.
Basset, George S., M.D. and Skaggs, David L, M.D.
Ibid.
Ibid.
Well-Connected.
Ibid.
Basset, George S., M.D. and Skaggs, David L, M.D.
Well-Connected.
Ibid.
Lonstein, John E.
Well-Connected.
The Spinal Connection. "Instrumentation systems for scoliosis surgery."
Bibliography
American Academy of Orthopaedic Surgeons: 1991 Annual Scientific Program
American Academy of Orthopaedic Surgeons: 1992 Annual Scientific Program
American Academy of Orthopaedic Surgeons: 1997 Annual Scientific Program
Archives of Pediatrics and Adolescent Medicine. "Non-operative Treatment of
The Backletter. "Bracing effective in slowing spinal curve."
The Backletter. "Disagreement over School Screening for Scoliosis."
Bassett, George S., M.D. and Skaggs, David L., M.D.
Blackman, Ronald, M.D.; O’Neal, Kelly, M.D.; and Picetti III, George, M.D.
Blackman, Ronald, M.D.; O’Neal, Kelly, M.D.; and Picetti III, George, M.D.
Clark, Stephanie. "New twists in scoliosis research." News. The Lancet.
Dick, Harold M. "Scoliosis." The Columbia University Collection of Physicians
Diguiseppi, Carolyn G., M.D., M.P.H. and Woolf, Steven H., M.D., M.P.H.
Farley, Dixie. "Correcting the curved spine of scoliosis."
Fenner, Louise. "When the spine curves." FDA Consumer.
Lonstein, John E. "Adolescent idiopathic scoliosis." Review Article.
Meade, Kevin P. Ph.D. "Orthotic treatment for Idiopathic Scoliosis:
The Merck Manual. "Developmental conditions: Idiopathic Scoliosis."
Mosby’s Medical, Nursing, and Allied Health Dictionary.
Richardson, Michael L., M.D. "Scoliosis." Rev. 6 Aug 1994. Online.
Science. "Memory Metal Unwinds Scoliosis." Vol. 265. 23 Sep 1994.
The Spinal Connection. "Bracing for adolescent idiopathic scoliosis."
The Spinal Connection. "Instrumentation Systems for scoliosis surgery."
The Spinal Connection. "School Screening." Vol. 11. No. 2.
Well-Connected. Scoliosis. Report #68. 1996.
The Surgical Treatment of Scoliosis. "What is Scoliosis? And how is it
US Preventive Services Task Force. "Screening for Adolescent Idiopathic
Winter, Robert B., M.D. Editorial. "A reply to the US Task Force Bracing
Woolf, Steven H., M.D., M.P.H. US Preventive Services Task Force. 47.
Meeting: Analysis of the Use of Contoured Harrington Rods and ISSI to Obtain
Transverse and Sagittal Plane Correction of Idiopathic Scoliosis. 11 March
1991. Online. http://www.aaos.org:80/cgi-bin/print_hit_bold.pl/wordhtml/anmeet91/scipro/ppr366.htm?Harrington#first_hit. July 1997.
Meeting: Hook Patterns for Idiopathic Scholiosis. 22 February 1992.Online.
http://www.aaos.org.
Pathway:80/cgi-bin/print_hit_bold.pl/wordhtml/anmeet92/scipro/ppr262.htm?
hook+patterns#first_hit. July 1997.
Meeting: Re-Entry Following Primary Posterior Instrumentation and Fusion
for Idiopathic Scoliosis: Harrington, Cotrel-Dubousset, and Isola Ha
Comparisons. 13 February 1997. Online. http://www.aaos.org.
Pathway: 80/cgi-bin/print_hit_bold.pl/wordhtml/anmeet97/scipro/064.htm?
re-entry+follow#first_hit. July 1997.
Scoliosis and Kyphosis." June 1994. Vol. 148. Pg. 646. Reprinted in Tips
from Other Journals from American Family Physicians. Pub. By American Academy,
of Family Physicians. Vol. 50. No. 6. 1 Nov. 1994. Pg. 1344.
Publication of the Back Pain Society. Vol. 6. No. 2. 1994. Pgs. 1 and 9.
Publication of the Back Pain Society. Vol. 10. No. 3. March 1995. Pg. 32.
"Adolescent Idiopathic Scoliosis: An Update." American Family Physician.
Pub. By American Academy of Family Physicians. Vol. 53. No. 7.,BR> 15 May 1996. Pgs. 2327-2334.
"Anterior Multiple level discectomy using an endoscopic exposure." 1995.
Kaiser Permanente Medical Center. Oakland, California. Online.
http://www.scoiosisrx.com/discecto.htm. 1996.
"Scoliosis Treatment." 1995. Kaiser Permanente Medical Center.
Oakland, California. Online. http://www.scoiosisrx.com. 1996.
Vol. 343. No. 8902. 9 April 1994. Pg.910.
& Surgeons Complete Home Medical Guide. Crown Publishers, Inc. 3rd Edition.
1995. Pgs. 635-636.
"The Family Physician’s Role in Adolescent Idiopathic Scoliosis."
Editorials. American Family Physicians. Pub. By American Academy of Family Physicians.
Vol. 53. No. 7. 15 May 1996. Pgs. 2268.
On the Teen Scene. FDA Consumer. Vol. 29. No. 6. July/August 1994. Pgs. 26-28.
Reprinted Sept. 1984. 2 pgs.
The Lancet. Vol. 344. No. 8934. 19 Nov 1994. Pgs. 1407-1412.
Current concepts." BioConcepts, Inc. Orthotic-Prosthetic Center.
Burr Ridge, Illinois. Online. http://mmae.lit.edu/soliosis/backtalk.html.
Section 15. Pediatrics and Genetics, 205. Physical conditions in adolescence.
Whitehouse Station, New Jersey. Merck & Co., Inc. 1996-1997.
Online. http://www.merck.com.
"Idiopathic scoliosis_Dictionary Definition."
http://www.rad.washington.edu/mskbook/scoliosis.html.
Pgs. 1806-1807.
Vol. 11. No. 2. Fall/Winter 1994. Pgs. 1 and 6.
Vol. 11. No. 1. Spring/Summer 1994. Pgs. 1, 4, and 5.
Fall/Winter 1994. Pg. 2.
Nidus Information Services, Inc. 31 Aug 1996.
treated?" Southern California Orthopedic Institute 1996. Online.
http://www.scoi.com/scoilio.htm.
Scoliosis: Policy Statement." Journal of the American Medical Association.
Vol. 269. No. 20. 26 May 1993. Pgs. 2664-2672.
Study." Spine. Reprinted by National Scoliosis Foundation. December 1995.
"Screening for Adolescent Idiopathic Scoliosis." Online.
http://text.nlm.nih.gov/cps/www/cps.53.html.