Effectiveness of psychosocial interventions for pediatric patients with scoliosis: a systematic review

Study design

This systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.16–18 Its protocol was prospectively registered and available on International Prospective Register of Systematic Reviews (PROSPERO).19

Search strategy

Relevant literature was identified by searching Medline, PsycINFO, Embase, EBSCO Cumulated Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) from database inception to March 2022. No language or publication date restrictions were applied. Searches were run for a combination of ‘psychosocial intervention’, ‘pediatric’, and ‘scoliosis’ using standardized subject and free-text terms, including synonyms and alternative spellings (online supplemental material 1). The search strategy was developed in collaboration with an information specialist (CW). Manual reference list searches of the articles included were conducted. We also searched for gray literature by (1) contacting authors of relevant conference abstracts or dissertations found through the electronic database search for associated publications and (2) screening ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) for completed relevant trials.

Selection criteria

Articles were included if they met the following selection criteria: (1) the study aimed to evaluate the effectiveness of a psychosocial intervention (defined below); (2) participants were pediatric patients (aged ≤21 years, the highest threshold used for defining pediatric patients in research and clinical practice) diagnosed with scoliosis; (3) the study reported at least one quantitative patient outcome (eg, psychological symptoms, treatment compliance) or health service outcome (eg, healthcare utilization) at any follow-up timeframe; (4) the full text was available to allow for data extraction and quality appraisal; and (5) the article was a primary study (ie, not review, editorial). We included all randomized controlled trials (RCTs) examining the efficacy of psychosocial interventions, irrespective of the comparison group used. We did not anticipate finding a large number of RCTs and therefore broadened our selection to include non-randomized studies as well.

We defined psychosocial interventions as ‘interpersonal or informational activities, techniques, or strategies that target biological, behavioral, cognitive, emotional, interpersonal, social, or environmental factors with the aim of improving health functioning and well-being’.20 Our review included studies whose intervention included a core psychosocial component (such as counseling, psychoeducation, or coordination of care). We excluded studies concentrating primarily on comparing surgery, bracing, or exercises with usual care, as their findings were unlikely to elucidate the impact of psychosocial interventions.

Data collection

All articles identified through the database search were imported into Covidence, an electronic software platform for managing reviews. Two independent reviewers (MvN did all of them and AR and KT split their role) screened articles’ titles and abstracts to determine if they met selection criteria and reviewed the full text of all articles deemed to be potentially relevant. Two reviewers (AR and MvN) independently (1) extracted the following data from eligible articles: study setting; study design; sample characteristics; intervention group and control group characteristics; all patient or healthcare outcome measure(s); and associated result(s) (eg, mean difference), and (2) conducted quality assessments of all randomized and non-randomized studies using the Cochrane Collaboration’s Risk of Bias Tool and Methodological Index for Non-Randomized Studies, respectively.21 22 Disagreements in article inclusion, data extraction, or quality assessment ratings were resolved through consensus discussion with a third independent reviewer (KT and JV).

Data analysis

The findings of the systematic review are presented using narrative synthesis and tables, highlighting the results of all outcome measures reported in eligible articles. Heterogeneity between psychosocial interventions included in the review (1) precluded pooling findings by meta-analyses and (2) made conducting formal analyses of causes of heterogeneity between studies unnecessary.

Overview

Totally, 6445 articles were identified through the electronic database and register searches. After removal of duplicates, 4238 titles and abstracts were screened, yielding 177 articles for full review. A total of 146 articles were excluded after reviewing the full paper, and 18 articles did not have full texts available for review. Ten studies (described in 13 papers) met the selection criteria, all of which focused on AIS (figure 1).23–35

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We included six clinical trials,23 28–34 three cohort studies,24–27 and one cross-sectional study.35 The included studies analyzed relatively small sample sizes (mean (range) of analyzed sample sizes: 101 (28–237)). Studies were primarily comprised of female adolescents (mean age range: 12–16 years; percentage of female range: 64%–100%). Five studies were conducted in the United States,23 29–33 35 two in China,25 26 34 one in Japan,24 one in Malaysia,27 and one in Canada.28 Four studies were conducted in the past 5 years,25–27 32 34 with publication dates ranging from 1985 to 2021.

Interventions for patients undergoing bracing

Three studies (described in four papers) focused on patients with AIS undergoing bracing treatment (online supplemental table 1).23–26 The studies analyzed a total of 344 participants, with the vast majority of participants being female (82%–100%).23–26 Participants who wore thoracic lumbar sacral orthosis (TSLO) braces were included in two studies,23 24 Milwaukee braces in one study,24 and Chêneau braces in one study.25 26 Studies examined two main categories of interventions: (1) brace compliance monitoring and counseling23 25 26 and (2) mental health-informed treatment planning.24

Interventions for patients undergoing spinal surgery

Six studies (described in eight papers) focused on patients with AIS undergoing spinal surgery (online supplemental table 2).27–34 The studies analyzed a total of 426 participants.27–34 Most were RCTs,28–34 and all but one study excluded patients with psychological, cognitive, and/or developmental conditions.27–31 33 34 Studies examined two main categories of interventions: (1) brief educational interventions28–30 32 33 and (2) intensive multidisciplinary care models.27 34

General interventions

Only one study included in this review broadly focused on patients with scoliosis (ie, not specifically bracing or spinal surgery) (online supplemental table 3).35 Hinrichsen, Revenson, and Shinn35 performed a cross-sectional study in 1985 comparing the psychological well-being of adolescents who attended a scoliosis self-help group with those who sought information about the group but did not yet attend. They found no significant between-group differences for most outcomes, including psychosomatic symptoms.35

Quality assessments

We summarize the results of our quality assessments in online supplemental tables 4 and 5.21 22 It was difficult to conduct quality assessments for many of the included studies due to limitations in their reporting quality, consequently also resulting in relatively low certainty in the body of evidence. For example, most RCTs did not clearly report their allocation concealment or outcome assessor blinding procedures, or lack thereof. Many non-randomized studies also did not clearly describe their sampling procedures, outcome assessor blinding procedures, or sample size calculations. Notably, several RCTs were deemed to have a high risk of bias for participant and clinician unblinding, incomplete outcome data, and selective outcome reporting.

Although not assessed by the quality assessment tools, it should be noted that a number of the studies were conducted more than 5 years ago, with one conducted in 1985 and several in the early 2000s.24 29–31 35 This may reduce their relevance and applicability to current clinical practice.24 29–31 35

Main findings

This systematic review aimed to summarize evidence of the efficacy of psychosocial interventions on patient and health service outcomes (such as psychological symptoms, treatment compliance, healthcare utilization) among pediatric patients with scoliosis in any setting. Ten eligible studies (described in 13 articles) were identified, all focusing on patients with AIS. More specifically, three focused on those undergoing bracing, six on those undergoing spinal surgery, and one on patients broadly. Brace compliance monitoring and counseling were found to significantly improve brace compliance quality and quantity in adolescents with scoliosis. Proactive mental healthcare delivery by nurses after spinal surgery was also found to significantly improve mental and physical health outcomes for these patients. Several studies examined the efficacy of brief educational interventions on postsurgical anxiety and/or pain; most did not report clear evidence of interventions being more efficacious than comparator interventions.

Discussion of main findings

Other relevant literature

To our knowledge, this is the first systematic review to examine the effectiveness of psychosocial interventions for pediatric patients with scoliosis. However, there are a number of additional relevant reviews worth noting.

Our review only included studies that reported quantitative data, as another recent review by Essex et al1 summarized relevant qualitative data. They highlighted the complex biopsychosocial needs of adolescents with scoliosis, including body image concerns and limitations in everyday activities.1 They also described several encouraging ‘simple’ interventions, including poetry writing and co-designing scoliosis braces, that may improve patient outcomes.1 However, reviewers also found that patients were often not adequately supported by providers, noting a need for improved information provision, ongoing emotional support (particularly to overcome barriers to brace compliance), and greater general attentiveness of clinical staff.1

Furthermore, our review only focused on pediatric patients with scoliosis because another review by Motyer et al3 summarized evidence on the experiences of parents of children with scoliosis, highlighting their information needs, treatment concerns, and psychological well-being. They found that parents often lacked treatment knowledge and consequently turned to the internet for information, which resulted in more confusion and distress.3 Therefore, they highlighted the importance of evidence-based resources for parents.3 Parents were also found to experience high levels of psychological distress and concern about their child’s treatments.3 Researchers have emphasized the important role that providers have in consistently supporting parents.3

Recommendations for future research and clinical practice

On completion of our review, we organized a consultation meeting, where we presented the review findings to a diverse group of scoliosis experts at our institution, including pediatric orthopedic surgeons, nurses, physical therapists, social workers, psychologists, researchers, and people with lived experience. After providing detailed descriptions of the included studies in the review, as well as the overall review results, we asked them to share their perceptions of integrating the interventions into clinical practice. Overall, group members were supportive of the proactive brace compliance monitoring and counseling intervention, but simultaneously cautioned against making patients feel ‘guilty’ when implementing this intervention. Group members also saw the value of intensive multidisciplinary interventions, such as training a provider to proactively deliver mental healthcare, as depicted in the study on Rosenthal effect-based nursing. Based on their clinical expertise, group members also recommended implementing structured support groups and one-on-one peer mentorship programs for patients and their caregivers, as well as developing evidence-based resources with practical information on living with scoliosis; these suggestions mirror those made in the two systematic reviews previously described.1 3 However, it should be noted that while peer support interventions have been shown to have potential value, limitations in the quality of the literature have prevented strong conclusions regarding their efficacy.36 37

We recommend that future clinical and research efforts be directed towards developing and implementing innovative models of care that integrate multiple interventions shown to have the most promise in the literature and clinical practice. One such model of care recommended by the World Health Organization (WHO) is case management (CM).38 CM often involves adding a new member to the care team, a case manager, to improve the coordination and delivery of holistic care.39 When appropriately implemented, CM has been found to have the potential to improve high-quality care for populations with diverse conditions.40 However, the efficacy of these types of complex, multidisciplinary models of care requires further investigation in pediatric patients with scoliosis. In addition, future research efforts should focus on other patient populations with scoliosis, such as those with neuromuscular scoliosis.

Strengths and limitations

This systematic review has several strengths which include: (1) using a comprehensive search strategy developed with an information specialist to find all relevant published literature; (2) not applying language or publication date restrictions; (3) minimizing selection bias by preregistering our protocol and using two independent reviewers for study selection; (4) minimizing reporting bias by using two independent reviewers for data extraction and quality assessments; (5) conducting rigorous quality assessments of all included studies; and (6) searching for gray literature.

This systematic review also has limitations which include the inclusion of: (1) a small number of studies, often with poor reporting quality; (2) non-randomized studies; (3) studies conducted more than five years ago, including one from 1985 and several from the early 2000s; (4) studies that almost exclusively focused on female adolescents with scoliosis, with little to no consideration for other populations, such as those with neuromuscular scoliosis; (5) studies that typically developed and tested brief one-off interventions, rather than intensive interventions or models of care likely to change overall care offered to those with scoliosis; and (6) studies that provided scant evidence of the efficacy of psychosocial interventions on physical health outcomes or long-term health outcomes. Other limitations of our review include: (1) our inability to conduct statistical analyses due to psychosocial intervention heterogeneity and (2) our gray literature search not retrieving any additional published literature for inclusion. However, we were encouraged to discover that a number of trials in this field are underway or have recently been completed, which will provide further insight into the effectiveness and potential of certain interventions.