Brace and deformity-related stress level in females with adolescent idiopathic scoliosis based on the Bad Sobernheim Stress Questionnaires

Background

The psychological aspects of scoliosis as a chronic disease, usually diagnosed in adolescence, are a source of stress and fear for patients, particularly when dealing with the illness’ diagnosis and treatment [1–6]. A critical period regarding stress levels has been identified as the initiation of conservative treatment [7–9]. Equally important, people with scoliosis experience a real sense of rejection by peers and feel stigmatised due to their appearance, which is magnified further by the specific problems of adolescence [10].

Scoliosis and its treatments hinder proper personality and identity development and disturb the development of body image. Psychopathological symptoms such as depression and neuroticism occur more often in chronically ill patients in adolescence than in healthy populations [11–13]. Bengtsson et al [14] found that psychopathological symptoms such as emotional hypersensitivity, dysphoric mood and aggressive behaviour may occur in patients with scoliosis.

An analysis of the literature shows that potential differences in the health-related quality of life between patients with adolescent idiopathic scoliosis treated operatively or conservatively have not been well explored, and the results of studies on this problem remain ambiguous [7,15–18]. Until now, attempts to assess the negative influence of conservative treatment on the condition of patients were usually carried out using general methods that did not take into account specific requirements related to using a brace [1,7,19–21]. Little attention has been paid to stress levels related to trunk deformations such as a rib hump, asymmetrical shoulders, waist and chest, or the degree of kyphosis, in patients treated using various methods [8,22]. There also limited data on the prevalence of such personality traits as the level of self-criticism, extra-introversion or the severity of self-reported psychopathological symptoms such as mania and paranoia in adolescents with scoliosis [11–13].

The majority of the research in this area has investigated long-term outcomes after brace or surgical treatment [4,21,23,24]. The aim of this study was to determine whether short-term differences exist in psychopathological symptoms between female adolescents with scoliosis treated surgically or conservatively, since it has been proven that even a treatment period as short as 3 months might negatively affect a patients’ health-related quality of life (HRQoL) [1,19]. Ugwonali et al. [20] and Matsunaga et al. [25] studied the effects of conservative treatment over an even shorter time span – a 4-week observation period from the start of treatment.

This cross-sectional study consists of 2 parts. The aim of the first part of the study was to compare stress levels related to trunk deformation and the use of an orthopaedic brace in patients treated conservatively, as well as in patients treated operatively with thoracoplasty, who for 12 weeks wore a brace to stabilize the chest after surgery. In the second part of the study we analysed the personality characteristics of adolescents with idiopathic scoliosis after brace or surgical treatment, compared to healthy controls.

Additional assessment involved the relation between the Cobb angle, the apical translation before and after treatment, percentage of scoliosis correction, the duration of brace wearing on a daily and monthly basis, stress levels and personality traits. This article presents the first part of the study.

Material and Methods

STRUCTURE OF THE STUDY:

Forty-three patients treated surgically and 55 patients treated conservatively who fulfilled the inclusion criteria received in-depth information on the aim of the study and were assured of anonymity. In order to proceed with asking patients to fill out the questionnaire, the patients gave their informed consent, which, for subjects under 18 years old, was granted by their parents. Seventy-three percent of patients treated surgically and 63.6% of those treated conservatively filled out the questionnaires. The assessed group consisted of 69 white females, of whom 35 were treated conservatively; 34 were treated operatively and after correction of scoliosis with thoracoplasty wore a brace for 12 weeks in the postoperative period. Patients were recruited into the study consecutively. They were treated in the Pediatric Orthopedics and Traumatology Clinic at the Poznan University of Medical Sciences by the same doctor. The age span for the whole group ranged from 12 to 18 years.

A homogenous group of female patients was included in the study group. The results of Sapountzi-Krepia et al. [4], Payne et al. [26] and a review of the studies carried out by Eliason and Richman [27] indicates, however, that a difference between the sexes exists in reaction to body deformation due to scoliosis and treatment methods. This may be due to the fact that higher values of the Cobb angle related to scoliosis occur more frequently in female patients [28]. The same selection criterion of choosing only female subjects in a study devoted to the psychological characteristics of patients with scoliosis treated operatively or conservatively was applied and justified in a similar study by Noonan et al. [29].

All the patients involved in the study attended public schools; 66.4% of patients attended high school, 29.8% were junior high school students and 3.8% attended primary school. Regarding place of residence, 31.7% of patients lived in rural locations, 27.9% lived in a town with a population of less than 25,000, 13.5% lived in a town with a population of 25,000 to 200,000, and the remaining 26.8% lived in cities with a population of over 200,000.

METHODOLOGY OF X-RAY EXAMINATION:

As provided by the Harms Study Group [30], X-ray images were taken in an upright position with the iliac ala exposed in an anterior-posterior projection. To assess the group that was treated operatively, we used x-ray images taken pre- and postoperatively. To assess the group that was treated conservatively, we used x-rays that were taken before the application of the Cheneau braces.

The following parameters adopted by D’Andrea et al. [30] were considered: the Cobb angle in the main curve, and the distance between the apical vertebra of scoliosis and the central sacral vertical line (in centimetres), described as the degree of the apical translation of the centre sacral vertical line. Moreover, we considered the location of the major deformation curve and, in cases where patients were treated operatively, the range of spondylodesis. Percentage of scoliosis correction was also taken into account.

PARTICIPANTS:

Inclusion criteria for the study group treated conservatively were as follows: female, 12–17 years old, minimum length of Cheneau brace wearing of at least 12 hours a day, Cobb angle of scoliosis of 20–40 degrees, a minimum period of 3 months of Cheneau brace wearing. Following the criteria of the Scoliosis Research Society regarding the location of apex [31], thoracic scoliosis was identified in 62.8% of the patients, thoracic-lumbar scoliosis in 31.4%, and lumbar scoliosis in the remaining 5.8%. No other diseases leading to deformity of the trunk were identified in patients treated conservatively. See Table 1 for additional information on the group treated conservatively.

Inclusion criteria for the group treated surgically were as follows: female, 12–18 years old, scoliosis treated surgically with thoracoplasty and the wearing of an underarm brace for a period of 3 months postoperatively. The minimum follow-up after which patients were asked to fill out the questionnaires in the surgically treated group was 3 months. The correction of scoliosis was the first operation carried out in the spinal region of these patients. None of patients suffered from postoperative complications that could have influenced the results.

Working analogically, as in the division of patients who underwent conservative treatment, using the criteria of the location of the apex according to SRS regulations [31], 82.4% of patients treated surgically were identified with thoracic scoliosis, 11.8% with thoracic-lumbar scoliosis, and 5.8% with lumbar scoliosis. Additional information on the group treated surgically is shown in Table 2.

METHODS:

Patients completed the Polish versions of the Bad Sobernheim Stress Questionnaire-Deformity (BSSQ-Deformity) and the Bad Sobernheim Stress Questionnaire-Brace (BSSQ-Brace). In earlier studies [32] we submitted the BSSQ-Brace and BSSQ-Deformity to a process of cultural adaptation to Polish conditions. The Polish versions of the BSSQ-Brace and BSSQ-Deformity received high scores for internal consistency and test-retest reliability [32].

BSSQ-Brace and BSSQ-Deformity serve to evaluate stress levels as a result of body deformation and stress levels relating to the use of a brace in scoliosis patients. Answers were marked on a 4-point scale, from 0 to 3 [22]. The number of points possible ranges from 0 to 24; the higher the score, the lower the level of stress felt by the respondent. The interpretations of the results are as follows: 0–8 points indicate a high level of stress; 9–16 points indicate a moderate level of stress, and 17–24 points indicate a low level of stress [22].

STATISTICS:

In respect to statistical quantitative features, we determined mean and standard deviations. In respect to qualitative features, we gave the number of units that belong to described categories of a given feature respective percentages. As the majority of considered features and results were not normally distributed, we used non-parametric tests to verify the hypothesis.

To establish relations between quantitative features, we used Spearman’s rank correlation (marked as rS). The Mann-Whitney test was used to compare the 2 groups in respect to a quantitative feature. As a border level of statistical significance we adopted p=0.05; test results whose p value exceeded this level were treated as insignificant. The same criterion in this kind of assessment was used by Weigert et al. [21]. Statistical calculations were performed using Statistica software.

ETHICAL CONSIDERATIONS:

The study design was approved by the Ethics Committee of Poznan University of Medical Sciences (approval number 268/08) and was carried out following universal ethics principles.

Results

The 2 analyzed groups do not differ in terms of weight (p=0.494), height (p=0.166), Body Mass Index (p=0.914) and the location of the major deformation curve (p=0.383). There are statistical differences in the characteristics among the 2 analyzed groups. In regards to the Cobb angle and the apical translation, we took into account both preoperative and postoperative values of the Cobb angle and the apical translation in the group treated surgically. The groups differed significantly in regards to the preoperative (p<0.001) and postoperative (p=0.004) values of the Cobb angle. The groups differed significantly in regards to the preoperative (p<0.001) and postoperative (p=0.025) values of the apical translation. A higher value of apical translation equates with a higher degree of decompensation and deformation of the trunk, which is related to aesthetics.

A homogenous group of only female patients was included in the study group. There are significant differences between patients treated with a brace and patients treated operatively in regards to age at assessment (p=0.001) and at initiation of treatment (p=0.002).

Patients treated surgically felt a moderate level of stress related to wearing a brace over a short follow-up after the surgical correction, as well as stress related to trunk deformation. Patients treated conservatively also felt a moderate level of stress related to wearing a brace, similar to the group treated surgically; however, the stress level related to body deformity was low (Table 2). This difference is statistically significant (p<0.001, Mann-Whitney test) (Table 2). This indicates that brace wearing increased the level of stress more than the stress induced by the deformity alone.

In comparison, the 2 groups have significant statistical differences solely in relation to stress levels due to body deformation (p=0.004), where the group treated surgically reported higher stress levels (Table 2).

In the group that underwent conservative treatment, we noted that the older the patients were when treatment began, the higher the stress due to wearing a brace. We also observed that the higher the apical translation, the higher the stress levels connected to trunk deformation, confirming our assumptions. There were no significant correlations between the value of the Cobb angle and the length of time the brace was worn, and stress levels in patients treated conservatively (Table 3).

Due to the existence of a significant statistical correlation (p=0.008) pre-operatively between the degree of translation and stress levels due to body deformation in patients treated conservatively, we attempted to identify a translation value that would divide the group into 2 parts with clearly different stress levels. Based on the analysis of correlation and the Mann-Whitney test result, it became evident that patients with a preoperative translation degree of less than 2.5cm displayed stress levels connected to trunk deformation (19.5 SD 3.6) significantly (p=0.015) lower than in patients with a degree of translation higher than or equal to 2.5 cm (15.2 SD 5.2).

Similarly, where there was a clear statistical correlation (p=0.029) between age at the start of treatment and stress levels due to the use of a brace in patients treated conservatively, we determined that patients who began treatment at age 13 or earlier felt stress levels (14.7 SD 3.8) significantly (p=0.018) lower than in patients who began treatment at the age of 13 or over (10.6 SD 4.5).

It appeared, contrary to our expectations, that in the surgically group treated there were no significant correlations between the preoperative and postoperative Cobb angle in the main curve and the apical translation, the percentage of correction of scoliosis after surgery, the range of spondylodesis, and the age of the patient, with BSSQ scores (Table 4).

Discussion

LIMITATIONS:

The cross-sectional character of our study constitutes a certain limitation; it was not possible to state whether there were differences between groups prior to treatment and whether such differences affected outcomes. An example may be the value of Cobb angle in both study groups, which contributes to different expectations of patients in regard to treatment results. Similar restrictions in sectional studies were indicated by Bunge et al. [24]. However, Climent and Sanchez [41] believe that cross-sectional studies are a valid option, due to the nature of the scoliosis and indications for application of various therapeutic approaches.

Studies herein require an adoption of an assumption relating to the issue of randomization. Such an assumption shows that there were no differences between groups that were treated surgically and conservatively in respect to measured traits of character prior to treatment. Such an assumption seems plausible, as the occurrences of scoliosis that require treatment is random. Similar problems and the need for adopting such an assumption were voiced by Noonan et al. [29].

Conclusions

There were differences in stress levels between female patients with scoliosis in the short-term after brace or surgical treatment – the group treated surgically had higher stress levels connected with body deformation. Our results show that patients already experiencing stress caused by trunk deformity had additional stress related to conservative treatment. Moreover, we found that a higher level of stress depends on the degree of trunk deformation on the frontal plane. Stress is also higher in patients who begin conservative treatment at a later age.