The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms.

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

Importance

Adolescent idiopathic scoliosis is a lateral curvature of the spine of unknown etiology with a Cobb angle (a measure of the curvature of the spine) of at least 10° that occurs in children and adolescents ages 10 to 18 years. It is the most common form of scoliosis and usually worsens during adolescence before skeletal maturity. In the United States, the estimated prevalence of adolescent idiopathic scoliosis with a Cobb angle of at least 10° among children and adolescents ages 10 to 16 years is 1% to 3%.^{1, 2} Most patients with a spinal curvature of greater than 40° at skeletal maturity will likely experience curvature progression in adulthood. Severe spinal curvature may be associated with adverse long-term health outcomes (e.g., pulmonary disorders, disability, back pain, psychological effects, cosmetic issues, and reduced quality of life).^{1, 3} Therefore, early identification and effective treatment of mild scoliosis could slow or halt curvature progression, before skeletal maturity, thereby improving long-term outcomes in adulthood.

Detection

The USPSTF found adequate evidence that currently available screening tests can accurately detect adolescent idiopathic scoliosis. The accuracy of screening was highest (93.8% sensitivity and 99.2% specificity) when three separate screening tests were used (e.g., the forward bend test, scoliometer measurement, and Moiré topography); accuracy was lower when screening programs used just one or two screening tests (e.g., 71.1% sensitivity and 97.1% specificity for the forward bend test and scoliometer measurement; 84.4% sensitivity for the forward bend test alone).

Benefits of Early Detection and Intervention or Treatment

The USPSTF found no direct evidence regarding the effect of screening for adolescent idiopathic scoliosis on patient-centered health outcomes. The USPSTF found inadequate evidence on the treatment of idiopathic scoliosis (Cobb angle <50° at diagnosis) in adolescents with exercise (two small studies) or surgery (no studies) or its effects on health outcomes or the degree of spinal curvature in childhood or adulthood. The USPSTF found adequate evidence (five studies) that treatment with bracing may decrease curvature progression in adolescents with mild or moderate curvature severity (an intermediate outcome). However, it found inadequate evidence on the association between reduction in spinal curvature in adolescence and long-term health outcomes in adulthood.

Harms of Early Detection and Intervention or Treatment

The USPSTF found no studies on the direct harms of screening, such as psychological harms or harms associated with confirmatory radiography. The USPSTF found inadequate evidence to determine the harms of treatment.

USPSTF Assessment

The USPSTF concludes that the current evidence is insufficient and that the balance of benefits and harms of screening for adolescent idiopathic scoliosis cannot be determined.

Patient Population Under Consideration

This recommendation applies to asymptomatic children and adolescents ages 10 to 18 years.

Screening Tests

Most screening tests for adolescent idiopathic scoliosis are noninvasive. Screening is usually done by visual inspection of the spine to look for asymmetry of the shoulders, scapulae, and hips. In the United States, the forward bend test is commonly used to screen for idiopathic scoliosis. First, a clinician visually inspects the spine of a patient while the patient is standing upright. Next, the patient stands with feet together and bends forward at the waist with arms hanging and palms touching. The clinician repeats the visual inspection of the spine.^{1, 4} A scoliometer, which measures the angle of trunk rotation, may be used during the forward bend test. An angle of trunk rotation of 5° to 7° is often the threshold for referral for radiography.¹ Other screening tests include a humpometer, the plumb line test, and Moiré topography (creating a three-dimensional image of the surface of a patient’s back) (Table 1).

If idiopathic scoliosis is suspected, radiography is used to confirm the diagnosis and to quantify the degree of curvature (i.e., the Cobb angle) and the Risser sign (the stage of ossification of the iliac apophysis).¹ U.S. organizations that advocate screening recommend the forward bend test combined with scoliometer measurement.

Treatment

The goal of treatment is to decrease or stop spinal curvature progression during the period of adolescent growth prior to skeletal maturity. Treatment of adolescent idiopathic scoliosis is determined by the degree of spinal curvature and potential for further growth and generally includes observation, bracing, surgery, and exercise.¹

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Most children and adolescents with scoliosis do not have symptoms. Generally, smaller spinal curvatures remain stable while larger curvatures tend to progress in severity.

Pulmonary dysfunction can be clinically significant in patients with spinal curvatures greater than 100°; however, curvatures of that severity are rare. Back pain is more common, but its effect on functioning or disability is unclear.¹ Current evidence suggests that the presence of back pain does not necessarily correlate with the degree of spinal curvature in adulthood. Adults with adolescent idiopathic scoliosis may have poor self-reported health, appearance, and social interactions. Mortality is similar to that among unaffected adults.¹

Potential Harms

Evidence on the harms of screening for adolescent idiopathic scoliosis is limited. False-positive results are an important potential harm, with rates ranging from 0.8% to 21.5%.^{1, 5, 6} However, the direct harms of screening are unclear. Potential harms of false-positive results include unnecessary followup visits, radiation exposure resulting in increased cancer risk, overtreatment, or psychosocial effects associated with the diagnosis of clinically insignificant scoliosis.¹

Current Practice

Various organizations have recommended routine screening for scoliosis in children and adolescents since the 1980s.^{1, 4} More than half of U.S. states either mandate or recommend school-based screening for scoliosis.^{1, 4, 7} Children and adolescents are usually screened with the forward bend test, with or without a scoliometer measurement.^{1, 4}

Generally, patients with a Cobb angle of less than 20° are observed without treatment; however, exercise may be recommended at this time. Patients with a Cobb angle greater than 30° or a Cobb angle of 20° to 30° that progresses 5° or more over 3 to 6 months are treated with bracing. Patients with a Cobb angle of 40° to 50° may be treated with bracing or surgery, while those with a Cobb angle greater than 50° typically require surgery.¹

Research Needs and Gaps

The USPSTF identified several research gaps. Prospective, controlled screening studies that would allow comparison of screened and nonscreened populations and different screening settings, personnel, and procedures are needed. High-quality studies on the potential harms of screening and treatment are also needed. Studies on long-term outcomes are needed, and should stratify results by degree of spinal curvature at diagnosis and at skeletal maturity. Better information on long-term outcomes such as pulmonary disorders, disability, back pain, psychological effects, cosmetic issues, and quality of life would be helpful. Good-quality studies on treatment with exercise, bracing, and surgery among screen-detected patients are needed.

Burden of Disease

The prevalence of adolescent idiopathic scoliosis (defined as a Cobb angle ≥10°) ranges from 1% to 3% among children and adolescents ages 10 to 16 years.^{1, 2} Cumulative incidence estimates for spinal curvature of greater severity are 1.0% (Cobb angle ≥20°) and 0.4% (Cobb angle ≥40°). Prevalence varies by sex, ranging from 0.15% to 0.66% in boys and from 0.24% to 3.10% in girls.¹ Prevalence of scoliosis with a Cobb angle of 10° is similar among girls and boys, but girls are 10 times more likely than boys to progress to a Cobb angle of 30° or greater. Girls are also 5 times more likely than boys to have a Cobb angle of 20° or greater.¹ The adverse effects of progressive scoliosis vary by its severity and include treatment costs, cosmetic deformity, reduced quality of life, disability, chronic back pain, social and psychological effects, functional limitations, and pulmonary disorders.¹

Scope of Review

The USPSTF reviewed the evidence on the benefits and harms associated with screening for and treatment of adolescent idiopathic scoliosis to update its 2004 recommendation.⁸

Accuracy of Screening Tests

Seven fair-quality observational studies assessed screening in adolescents (n=447,243).¹ Four studies evaluated the forward bend test with scoliometer measurement, one study evaluated the forward bend test with scoliometer measurement and Moiré topography, and one study evaluated screening with a single test (forward bend test or Moiré topography). Studies were conducted in seven different international sites, including one from the United States. Other countries included Hong Kong, Greece, Ireland, and Norway. Six studies were conducted in school-based settings.¹ There was heterogeneity in the screening approaches, screening procedures, and training of the screeners (e.g., orthopedists, nurses, and physical education teachers). Studies provided a limited description of screening populations and subgroups; three studies had followup data on children who screened negative. Five studies reported results of a single screening episode; two studies reported cumulative results of multiple years of repeated screening.¹ Studies used a Cobb angle of 10° or greater of the major spinal curvature as the threshold for a diagnosis of scoliosis.¹

Screening accuracy improved with the number of screening tests used. Sensitivity and positive predictive value (PPV) of screening programs varied based on whether a single screening test or multiple tests were used and by the selected threshold for a positive screening result.

Sensitivity and Specificity

One study evaluated screening with a combination of the forward bend test, scoliometer measurement, and Moiré topography and reported the highest sensitivity (93.8% [95% confidence interval (CI), 93.3 to 94.3]) and specificity (99.2% [95% CI, 99.2 to 99.2]).^9-11 A study of the forward bend test combined with scoliometer measurement had lower screening accuracy (71.1% sensitivity [95% CI, 54.1 to 84.6] and 97.1% specificity [95% CI, 96.3 to 97.7]).⁵ The forward bend test alone had 84.4% sensitivity (95% CI, 67.2 to 94.7) and 95.2% specificity (95% CI, 94.3 to 95.9); the humpometer had 93.8% sensitivity (95% CI, 79.2 to 99.2) and 78.5% specificity (95% CI, 76.9 to 80.0); the scoliometer had 90.6% sensitivity (95% CI, 75.0 to 98.0) and 80.7% specificity (95% CI, 79.1 to 82.1); and Moiré topography had 100% sensitivity (95% CI, 84.2 to 100) and 85.4% specificity (95% CI, 84.0 to 86.7).⁶

False-Positive and False-Negative Results

One study evaluated screening with a combination of the forward bend test, scoliometer measurement, and Moiré topography and reported a low false-negative rate (6.2%) and the lowest false-positive rate (0.8%).^{2, 11} A study of the forward bend test combined with scoliometer measurement had a 2.9% false-positive rate and a 28.9% false-negative rate.⁵ Single screening tests were associated with the highest false-positive rates (scoliometer, 19.3% [9.4% false-negative rate]; Moiré topography, 14.6% [0% false-negative rate]; and humpometer, 21.5% [6.3% false-negative rate]).⁶

PPV

One study evaluated screening with a combination of the forward bend test, scoliometer measurement, and Moiré topography and reported the highest PPV (81.0% [95% CI, 80.3 to 81.7]).^9-11 PPV for the forward bend test plus scoliometer measurement ranged from 29.3% ⁵ (95% CI, 20.3 to 39.8) to 54.1% (95% CI, 40.8 to 66.9).^12-14 PPV ranged from 5.0% (95% CI, 3.4 to 7.0) to 17.3% (95% CI, 11.7 to 24.2) for a single screening test (i.e., humpometer or the forward bend test alone).^{2, 6}

Effectiveness of Early Detection and Treatment

Brace Treatment

The USPSTF found seven studies on the effectiveness of treatment of adolescent idiopathic scoliosis. Five of these studies (n=651) evaluated the effectiveness of three different types of braces. The five studies included three trials (one fair-quality randomized, controlled trial [RCT] and one fair- and one good-quality prospective clinically controlled trial [CCT]; n=347);^14-16 and two observational studies (one good-quality prospective observational study and one fair-quality retrospective observational study; n=304).^{17, 18} Two trials were stopped early for observation of benefit; the good-quality prospective CCT began as an RCT but was changed to a patient preference controlled trial to boost enrollment after low acceptance of random assignment.¹

Studies included a comparison group that originally was not treated with bracing. The studies had a prespecified clinical threshold for the initiation of treatment. Three studies enrolled participants who had not previously received treatment for scoliosis; two studies did not provide details on prior treatment. Study sample sizes ranged from 37 to 242 participants. The studies were conducted in five countries, including Canada, Sweden, the United Kingdom, and the United States.¹

Study participants were recruited from specialty orthopedic centers and school screening programs. Average age at study enrollment ranged from 10 to 15 years. Race/ethnicity was poorly reported; in the one trial where it was reported, 78% of participants were white. Most participants were female. Study participants had various types of scoliotic curves; curvature severity varied from about 20° to approximately 30°. Eighty-five percent of participants had not reached skeletal maturity (Risser sign, 0 to 2).¹

Three controlled prospective studies (n=345) suggested a benefit of treatment with bracing on slowing curvature progression of 5° or 6° compared with observed controls;^{1, 16, 19, 20} one prospective study (n=37) and one retrospective study (n=64) showed limited differences in curvature progression of 10° or more between treatment and observed control groups.^{2, 14, 15} Four studies (n=411) evaluated curvature progression to a degree considered to be a failure of treatment.^{11, 16, 20, 21} The largest of these studies (n=242) demonstrated a significant benefit associated with bracing. The RCT (n=68) suggested lesser curvature progression in the treatment group, but the significance was not reported.¹ Two smaller studies (n=101) found similar results among treated and control populations.^{2, 14, 21}

The aforementioned large study (n=242) was a good-quality, international prospective CCT (Bracing in Adolescent Idiopathic Scoliosis Trial) that evaluated the effectiveness of bracing for 18 hours per day. The study included a randomized cohort (n=116) and a preference cohort (n=126). Analysis was conducted based on intention to treat and as treated. The rate of treatment success in the as-treated analysis (which included both the randomized and patient preference cohorts) was 72% in the intervention group and 48% in the control group (odds ratio, 1.93 [95% CI, 1.08 to 3.46]).^{1, 2, 22} In the intention-to-treat analysis (the randomized cohort only), the rate of treatment success was 75% in the intervention group and 42% in the control group (odds ratio, 4.11 [95% CI, 1.85 to 9.16]).^{1, 2, 22} The number needed to treat in order to prevent 1 case of curvature progression past 50° was 3.0 (95% CI, 2.0 to 6.2), and the reduction in relative risk with bracing was 56% (95% CI, 26 to 82).^{1, 2, 22} The Bracing in Adolescent Idiopathic Scoliosis Trial was the only study that reported quality of life outcomes associated with bracing; outcomes were shown to be similar between treatment groups.

One study, the Scoliosis Research Society (SRS) bracing cohort, assessed Cobb angle in adulthood.^{23, 24} Of the original 106 participants enrolled at two centers in the SRS bracing cohort, 77 were re-evaluated as adults (average age, 32 years). The study demonstrated that the average Cobb angle at skeletal maturity was similar in both the observed and treated groups (30.6° vs. 27.7°, respectively; p=0.067). At adult followup, the average Cobb angle had increased by an average of 4.4° (standard deviation, 4.1°) in observed participants and by 6.4° (standard deviation, 5.8°) in treated participants. Only 7.5% of observed participants and 5.4% of treated participants had curvature progression past 45° at the time of followup (p>0.99).^{1, 2}

Exercise Treatment

Two Italian trials (n=284) evaluated the effectiveness of exercise treatment (tailored physiotherapeutic, scoliosis-specific exercise). The trials used control groups in which participants were assigned to an exercise program not developed to specifically treat scoliosis. Trial participants had a Cobb angle ranging from 10° to 25°; skeletal maturity ranged from a Risser sign of 0 to 3. Patients were older than age 10 years.²

In the good-quality RCT (n=110)¹⁸ and the fair-quality CCT (n=74),¹⁷ the intervention group showed significant improvement compared with a generic exercise control group at the 12-month followup. In the RCT, intervention group participants had a reduction in Cobb angle of 4.9° compared with an increase of 2.8° in the control group (p<0.001).^{1, 2, 17, 18} Quality-of-life measures were improved at 12 months in the intervention group compared with marginally improved or unchanging measures in the control group. At the end of the 12-month treatment period, the intervention group had a decrease in average magnitude of all spinal curvatures of 0.67°, compared with a progression of 1.38° in the control group (p<0.05).^{2, 17, 18}

Surgical Treatment

The USPSTF found no studies of surgical treatment in screening-relevant populations that met inclusion criteria.

Association Between Severity of Spinal Curvature in Adolescence and Health Outcomes in Adulthood

The USPSTF found no studies that directly addressed whether changes in the severity of spinal curvature in adolescence results in changes in adult health outcomes. The USPSTF found no studies that reported health outcomes stratified by degree of spinal curvature at skeletal maturity. Two fair-quality studies provided data on adult health outcomes, stratified by the type of treatment received in adolescence.

The USPSTF considered two fair-quality, retrospective observational long-term followup analyses (n=339) of adults diagnosed with idiopathic scoliosis in adolescence. Adult outcomes were stratified by the type of treatment received in adolescence (bracing or surgery). Quality of life, as measured by the SRS-22 Patient Questionnaire or the 36-Item Short-Form Health Survey, was similar between observed and treated participants at adult followup. No significant differences were found between braced and surgically treated participants in the Oswestry Disability Index or in general well-being, self-esteem, and social activity. Pulmonary and pregnancy outcomes were also similar between braced and surgically treated participants. However, braced participants rated their body appearance as more distorted than did untreated participants and reported more negative treatment experiences than those treated with surgery.^{1, 2, 25-27}

Potential Harms of Screening and Treatment

The USPSTF found no studies on the direct harms of screening for adolescent idiopathic scoliosis. False-positive rates ranged from 0.8% for the forward bend test combined with scoliometer measurement and Moiré topography to 21.5% for hump assessment alone. Potential harms associated with false-positive results include psychological harms and chest radiation and other harms of unnecessary treatment.

The USPSTF found no studies that assessed the harms of treatment with surgery or exercise. Harms of bracing were reported in one good-quality study (n=242).^{21, 22} In this prospective CCT, intervention group participants were more likely to experience skin problems under the brace than control group participants (12/146 vs. 0/96, respectively). Intervention group participants more commonly reported nonback body pain than control group participants (12/146 vs. 2/96, respectively). The study reported low rates of anxiety and depression. Three out of 146 participants in the intervention group reported anxiety and depression compared with 1 out of 96 participants in the control group. One of the intervention group participants reported a serious adverse event (anxiety and depression requiring hospitalization) compared with none in the control group. The intervention and control groups had similar rates of abnormal breast development, neurologic symptoms, and gastrointestinal or respiratory symptoms.^{21, 22}

Estimate of Magnitude of Net Benefit

The USPSTF found no direct evidence on screening for adolescent idiopathic scoliosis and health outcomes. The USPSTF found adequate evidence that currently available screening tests can detect adolescent idiopathic scoliosis but no evidence on the harms of screening. The USPSTF found inadequate evidence on treatment with exercise and surgery; it found adequate evidence that treatment with bracing may decrease progression in adolescents with mild or moderate curvature severity. However, the USPSTF found inadequate evidence on the association between reduction in spinal curvature in adolescence and long-term health outcomes in adulthood. The USPSTF found inadequate evidence on the harms of treatment. Therefore, the USPSTF concludes that the current evidence is insufficient and that the balance of benefits and harms of screening for adolescent idiopathic scoliosis cannot be determined.

How Does Evidence Fit With Biological Understanding?

Mild or moderate idiopathic scoliosis (i.e., Cobb angle of <40° to 50°) is often asymptomatic in adolescence. In addition, the majority of cases of scoliosis will not substantially progress during adolescence. The likelihood of progression in adulthood is small for persons with a spinal curvature of less than 30° at skeletal maturity. However, there is no validated way to easily identify which cases of asymptomatic scoliosis will clinically worsen during adolescence and lead to poor long-term outcomes.

This recommendation updates the USPSTF 2004 recommendation, in which the USPSTF recommended against routine screening for idiopathic scoliosis in asymptomatic adolescents (D recommendation).⁸ In 2004, the USPSTF found fair evidence that treatment of adolescent idiopathic scoliosis leads to health benefits (i.e., decreased pain and disability) in a small proportion of persons. The USPSTF bounded the harms of treatment of screen-detected adolescent idiopathic scoliosis as moderate (e.g., unnecessary brace wear or unnecessary referral to specialty care). Therefore, the USPSTF concluded that the harms of screening exceeded the potential benefits.⁸

To update its recommendation, the USPSTF commissioned a new systematic review of the evidence. The review found some evidence of a benefit of treatment with bracing. However, evidence on the association between the magnitude of spinal curvature at skeletal maturity and adult health outcomes is lacking. The USPSTF also found limited evidence on the harms of screening and treatment. Due to the evolving nature of the evidence, the USPSTF determined that the evidence now reflects a decrease in the certainty of net benefit (from fair to low), leading it to issue an I statement.

Several national specialty groups have published statements in support of screening. The American Academy of Orthopaedic Surgeons, the SRS, the Pediatric Orthopaedic Society of North America, and the American Academy of Pediatrics advocate screening for scoliosis in girls at age 10 and 12 years and once in male adolescents at age 13 or 14 years as part of medical home preventive services, if performed by well-trained screening personnel.²⁸ The U.K. National Screening Society does not recommend screening for scoliosis given the uncertainty surrounding the effectiveness of screening and treatment.²⁹ However, the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment recommends screening for idiopathic scoliosis through school-based programs, and that screening should be performed by clinicians who specialize in spinal deformities.³⁰

1. Dunn J, Henrikson NB, Morrison CC, Nguyen M, Blasi PR, Lin JS. Screening for Adolescent Idiopathic Scoliosis: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 156. AHRQ Publication No. 17-05230-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2017.

2. Weinstein SL. Natural history. Spine (Phila Pa 1976). 1999;24(24):2592-600.

3. Dunn J, Henrikson NB, Morrison CC, Nguyen M, Blasi PR, Lin JS. Screening for adolescent idiopathic scoliosis: a systematic review and evidence report for the U.S. Preventive Services Task Force. JAMA. 2017. In press.

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5. Yawn BP, Yawn RA, Hodge D, et al. A population-based study of school scoliosis screening. JAMA. 1999;282(15):1427-32.

6. Karachalios T, Sofianos J, Roidis N, et al. Ten-year follow-up evaluation of a school screening program for scoliosis: is the forward-bending test an accurate diagnostic criterion for the screening of scoliosis? Spine (Phila Pa 1976). 1999;24(22):2318-24.

7. Linker B. A dangerous curve: the role of history in America’s scoliosis screening programs. Am J Public Health. 2012;102(4):606-16.

8. U.S. Preventive Services Task Force. Screening for idiopathic scoliosis in adolescents: recommendation statement. Rockville, MD: Agency for Healthcare Research and Quality; 2004.

9. Luk KD, Lee CF, Cheung KM, et al. Clinical effectiveness of school screening for adolescent idiopathic scoliosis: a large population-based retrospective cohort study. Spine (Phila Pa 1976). 2010;35(17):1607-14.

10. Lee CF, Fong DY, Cheung KM, et al. Referral criteria for school scoliosis screening: assessment and recommendations based on a large longitudinally followed cohort. Spine (Phila Pa 1976). 2010;35(25):E1492-8.

11. Fong DY, Cheung KM, Wong YW, et al. A population-based cohort study of 394,401 children followed for 10 years exhibits sustained effectiveness of scoliosis screening. Spine J. 2015;15(5):825-33.

12. Goldberg CJ, Dowling FE, Fogarty EE, et al. School scoliosis screening and the United States Preventive Services Task Force. An examination of long-term results. Spine. 1995;20(12):1368-74.

13. Goldberg CJ, Dowling FE, Fogarty EE. Adolescent idiopathic scoliosis: is rising growth rate the triggering factor in progression? Eur Spine J. 1993;2(1):29-36.

14. Goldberg CJ, Dowling FE, Hall JE, et al. A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls. Spine (Phila Pa 1976). 1993;18(7):902-8.

15. Wiemann J, Shah S, Price C. Nighttime bracing versus observation for early adolescent idiopathic scoliosis. J Pediatr Orthop. 2014;34(6):603-6.

16. Coillard C, Circo A, Rivard C. A prospective randomized controlled trial of the natural history of idiopathic scoliosis versus treatment with the SpineCor brace. SOSORT Award 2011 winner. Eur J Phys Rehabil Med. 2014;50(5):479-87.

17. Monticone M, Ambrosini E, Cazzaniga D, et al. Active self-correction and task-oriented exercises reduce spinal deformity and improve quality of life in subjects with mild adolescent idiopathic scoliosis. Results of a randomised controlled trial. Eur Spine J. 2014;23(6):1204-14.

18. Negrini S, Zaina F, Romano M, et al. Specific exercises reduce brace prescription in adolescent idiopathic scoliosis: a prospective controlled cohort study with worst-case analysis. J Rehabil Med. 2008;40(6):451-5.

19. Nachemson AL, Peterson LE. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am. 1995;77(6):815-22.

20. Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med. 2013;369(16):1512-21.

21. Wiemann J, Shah S, Price C. Nighttime bracing versus observation for early adolescent idiopathic scoliosis. J Pediatr Orthop. 2014;34(6):603-6.

22. Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Design of the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST). Spine (Phila Pa 1976). 2013;38(21):1832-41.

23. Nachemson AL, Peterson LE. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am. 1995;77(6):815-22.

24. Peterson LE, Nachemson AL. Prediction of progression of the curve in girls who have adolescent idiopathic scoliosis of moderate severity. Logistic regression analysis based on data from The Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am. 1995;77(6):823-7.

25. Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL. Health-related quality of life in untreated versus brace-treated patients with adolescent idiopathic scoliosis: a long-term follow-up. Spine (Phila Pa 1976). 2010;35(2):199-205.

26. Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL. Body appearance and quality of life in adult patients with adolescent idiopathic scoliosis treated with a brace or under observation alone during adolescence. Spine (Phila Pa 1976). 2012;37(9):755-62.

27. Danielsson A, Wiklund I, Pehrsson K, Nachemson A. Health-related quality of life in patients with adolescent idiopathic scoliosis: a matched follow-up at least 20 years after treatment with brace or surgery. Eur Spine J. 2001;10(4):278-88.

28. Hresko MT, Talwakar VR, Schwend RM. Position Statement: Screening for the Early Detection for Idiopathic Scoliosis in Adolescents. SRS/POSNA/AAOS/AAP Position Statement. 2015. https://www.srs.org/about-srs/news-and-announcements/position-statement---screening-for-the-early-detection-for-idiopathic-scoliosis-in-adolescents. Accessed May 23, 2017.

29. UK National Screening Committee. Screening for Adolescent Idiopathic Scoliosis: External Review Against Programme Appraisal Criteria for the UK National Screening Committee (UK NSC). 2011. http://www.britscoliosissoc.org.uk/data/documents/1466-13.pdf. Accessed May 23, 2017.

30. Negrini S, Aulisa AG, Aulisa L, et al. 2011 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis. 2012;7(1):3.