
My school district has some of school nursing’s best-of-the-best-of-the-best school nurses. Ain’t none of them ever punched me in my nose, and ain’t none of them called me “male nurse”…too often. The other day, during our meeting, we talked about a lot of things (which is what folks usually do during a meeting). One topic was the district’s policies and procedures specific to us school nurses when it comes to caring for the children from screenings for pediculosis to screening for scoliosis.
The question presented by the group was: “Should scoliosis screenings be something we school nurses do during the school year?” We were all asked to reflect on and plan on discussing this topic during our next meeting.
We may not get fully into ‘what is scoliosis’ in this article, but we will talk a little bit about scoliosis screening. When it comes to children, we’ve known “forever” that early diagnosis and prompt treatment can mitigate a bit of misery in their little world (both present and future). Back in the early 1960s, an orthopedist named G. Dean MacEwen, MD encouraged schools to institute a scoliosis screening program. It makes complete sense, right? A large number of young children are all concentrated at the same place and at the same time. Why not screen the “gathered” high-risk population and get the biggest bang for the buck?
Despite the initial intention of districts across the country in implementing in-school scoliosis screening back in the ’60s, as time went on, these screening programs have gone the way of the dodo bird. But why? To put it plainly: It’s likely due to a lack of supporting data showing that there is minimal harm (as well as cost-effectiveness) to those being screened. That’s not a personal bias; there are just so few studies that show:
- That children with scoliosis-like symptoms would be “missed” altogether if an in-school screening program did not exist.
- That scoliosis screening in school effectively identifies the children with scoliosis AND those without scoliosis (later we’ll talk about the false positives and the false NEGATIVES).
If you’re saying “shame on Nurse Kevin for saying ‘cost-effective’ when it comes to the children.” Hang on to that hate email; I ain’t the one payin’ the bills around here and surely ain’t the one making decisions. Politicians and policy-makers look at cost in making policies…period! If the cost cannot be justified, they will likely not support it. What I am saying is that the “supporting data” that in-school screenings are cost-effective does not exist to the extent where a “finger can be put on the number.”
I grew up in the ’70s and ’80s; I have no memory of having been screened for scoliosis at school. I am sure I was screened at the one of many regular pediatrician appointments that my mother diligently took me to, though I don’t remember a screening there, either. What I remember are two things about going to the doctor’s office back in those days: 1) You had to get naked (down to the BVDs), and 2) you got a shot. I now know why we had to get naked…so the doctor could look at our backs (among other details of our birthday suits).
It’s clear that many of the children we care for at our schools are growing up in a much different “world” than we grew up in. I am not talking about the “world” in the 21st century. I am talking about children with some really broken-up little “worlds.” Some of these children go to the doctor (maybe) only whenever they are sick or injured enough to miss school and visiting whatever quick care or urgent care with an empty chair in the waiting room (a rarity in and of itself). Those PAs and NPs (and maybe an MD or DO (if you’re lucky) are very unlikely to assess for anything other than the urgent need that the parent brought their child in with. Performing an Adam’s forward-bend test is simply not going to happen.
A trick question
Is screening for scoliosis at school by the school nurse a good or bad thing? Ha! A trick question, right? Many of us will lean toward “good” as being the answer to that question. After all, “early detection” and all that, right? We screen for vision, hearing, dental, and maybe a thing or two more during the school year. Why not screen for scoliosis?
I’ve looked for a solid and substantiating study on in-school scoliosis screening that would support the benefits of in-school screening and not just the cost-effectiveness of the screening, either. Unfortunately, there are no large studies. “The current available evidence in the literature for routine scoliosis screening is low to moderate.” But what about “the one child” that got missed? What I mean is this: what if you were to assess 450 children and find one child early enough to make a difference? Would that make in-school screenings worth it? But, what about the other 449 students? How will they feel having to show their bare backs to school staff that they see everyday? What about the time involvement? Would spending time preparing the screenings, promoting the screenings, performing the screenings, documenting the findings, calling the parents, and following up with the parents be time well spent? Sure! A