Postural Screening

CLINICAL GUIDELINES

Physicians and registered nurses (RNs), with the proper training, may perform postural screening. Some states mandate screening in schools for scoliosis and spinal abnormalities. In this case, most screenings are performed by the school nurse and educational staff who are properly trained by clinicians, depending on the district policy.
Screenings may be performed at any age but are usually performed during adolescence when the body is going through rapid physical growth. During mass screening, boys and girls must be screened separately and individually.

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Obtain history of back pain and family history of spinal curvatures.
Advise the child/adolescent that the shirt and shoes must be removed during screening; girls may keep their bra on.
Children and adolescents are often embarrassed by the screening procedure. Attempt to minimize the child’s anxiety. Reassure by explaining the steps that will be taken to assure that their privacy will be protected.
Teach the child/adolescent that the entire procedure takes 1 to 2 minutes and should effectively detect or rule out early signs of spine curvature. Early identification allows for prompt evaluation and treatment, avoiding possible cosmetic concerns and functional impairment.

PROCEDURE
Conducting Postural Screening

Steps	Rationale/Points of Emphasis
1 Perform hand hygiene.	Reduces transmission of microorganisms.
2 Ask the child to remove shirt and shoes. Girls may keep their bra on if not wearing a gown.	The bare back must be viewed to properly see the curves of the spine. The feet must be flat on the floor to avoid any false curvature caused by improper stance or shoes. KidKare When mass screening is performed (e.g., at school), have the girls wear or bring a bathing suit top to wear on the day of scoliosis screening; sports bras may cover the scapula and obscure visualization and therefore are not optimal. It may facilitate testing if a placement marker (e.g., an object or tape line) is placed to guide the child where to stand. Make arrangements for extra privacy in special cases such as girls without bras and obese students.
3 Ask the child to stand erect, arms hanging relaxed at sides.	Allows the body to assume a relaxed position.
4 Stand in front and then behind the child, assessing for obvious abnormalities (see Figure 89-1): Visualize the back and assess the position of the spine for curvature. Compare the shoulder and hip level for equality or if one side is higher than the other. Compare the shoulder blades; evaluate if one side is more prominent than the other. Look at the space between the arms and the body for equal distances between the arms and the flank. Observe waist crease, if present; evaluate if the creases or skin folds at the waist are equal on both sides. Compare leg lengths for equality. This is done by comparing hip symmetry while feet are flat on the floor in a standing position.	Shoulders, shoulder blades, and hips should be level, spine straight, and arms should have equal distances from the body. Leg length and waist creases, if present, should be equal on both sides. Possible scoliosis if inequality is present.
	caREminder
	If hips are not symmetric while standing, have the child sit on the edge of a chair or bench and assess the hip and shoulder symmetry. If the hips and shoulders are symmetric while sitting, then the legs are not equal.
Figure 89-1 A: The examiner begins by viewing the child from the back, looking for symmetry of the shoulders, scapulae, and waist creases. B: Next, the child is asked to place her hands together and bend forward. The examiner uses a scoliometer to obtain a rough estimate of the degree of spinal curvature. C: The examiner looks from the front for anterior chest deformity or asymmetry. D: When the child bends forward toward the examiner, particular curves may become more visible. E: Observing the child from the side allows the examiner to assess for kyphosis and lordosis. (From Bowden, V. R. [2014].
5 Instruct the child to assume the forward bend position (Adams test), observing from the front, side, and back: Feet 4 inches apart Knees straight Bend at the waist at 90 degrees Arms hanging, relaxed Palms of the hand facing each other, like diving into a pool Head down, chin to chest	Position allows observation of the spine while it is curved. Asymmetry in upper or lower back, rib cage, and hip level or lateral curvature of the spine suggest scoliosis. Excessive prominence of the thoracic spine suggests kyphosis, and excessive sway back suggests lordosis. KidKare If needed, demonstrate what they are being asked to do, so that they can see what it looks like.
6 If any asymmetry or prominence is noted, measure the angle of truncal rotation (ATR) by placing the scoliometer at the top of the thoracic spine, with the 0 (zero) mark over the spinous process, and slowly move the scoliometer down the spine noting the degree of truncal rotation by reading the number where the ball moves in line, either to the left or the right of the zero mark. This is the degree of rotation.	Determines degree of curvature.
	caREminder
	If asymmetry is present in both the upper and lower back, obtain two scoliometer readings. In this instance, the curves typically go in the opposite direction because of compensatory mechanisms.
7 Ask the child to put the shirt and shoes back on and commend for a job well done.	Positive reinforcement allows the child to walk away from the screening feeling proud and alleviates the initial feelings of embarrassment and anxiety.
8 Perform hand hygiene.	Reduces transmission of microorganisms.