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February 27, 2019

By Christopher Vara, MD; Sarah Kelly, DPT, Shriners Healthcare For Children — Twin Cities

Adolescent idiopathic scoliosis (AIS) can be a frustrating diagnosis because the cause is unknown in more than 80 percent of cases. Shriners Healthcare for Children — Twin Cities offers a non-traditional 3D treatment approach for AIS. Therapists instruct patients using scoliosis specific exercises (SSE) according to the principles of Christina Lehnert-Schroth and the Barcelona Scoliosis Physical Therapy School (BSPTS). This program targets the AIS population, but can also be used to treat juvenile idiopathic scoliosis and several sagittal plane disorders, including Scheuermann’s kyphosis.   

At Shriners Healthcare for Children — Twin Cities more than 60 patients have seen improvements in postural control, pain reduction, strength and overall quality of life since inception of the SSE program two years ago. Here patients have the benefit of a low dose 3D EOS radiation imaging system, in-house orthotists for custom bracing, and expert care from pediatric orthopedic surgeons.

Various factors are considered to determine if a patient is ideal for our program, including but not limited to, Cobb angle, age, Risser score, menstruation, and other radiological findings. Research indicates that younger, skeletally immature patients with a higher Cobb angle at diagnosis correlate to a higher risk of progression and an increased need for possible bracing or surgery.

When postural asymmetries are noted and the Adam’s forward bend test is performed, the use of a scoliometer can be a very helpful tool to assess the angle of trunk rotation (ATR). The 2013 SRS recommendation for measuring ATR is 7 degrees to make a referral.

Comparison of postures in scoliosis patient


On the left: An SSE patient with AIS habitual standing posture
On the right: The same SSE patient with active stabilization in her corrected posture

The SSE program focuses on educating patients about body awareness while using sensory-motor and kinesthetic training, with a goal of creating stability around their corrected posture. The program empowers patients by providing them with an active role in their treatment.

Scoliosis Specific Exercises:

  • Improve aesthetics via postural correction
  • Address respiratory dysfunction
  • Reduce functional limitations
  • Minimize the progression of the spinal deformity

The SSE program is time intensive and requires multiple follow-up sessions over a span of time relative to the patient’s risk of progression. Patients are prescribed a daily home exercise program including education on adapting posture, and they are instructed to avoid activities that may negatively impact their spine. Successful outcomes are directly correlated to the patient’s compliance with their home exercise program.

Historically, high-quality evidence supporting physical therapy and scoliosis has been hard to find but now there is new and ongoing research regarding the impact of physical therapy on scoliosis. A recent study by Kwan et al. in 2017 in the journal Scoliosis and Spine Disorders revealed that Schroth exercise, in combination with bracing, was superior to bracing alone in improving Cobb angles, trunk rotation, and quality of life scores. Additionally, patients who were compliant with their exercise program had a higher rate of Cobb angle improvement.

Shriners Healthcare for Children — Twin Cities has two therapists certified in SSE: Sarah Kelly, DPT and Rebecca Rouse, DPT.  Both are BSPTS C1 and C2 certified to treat scoliosis and have extensive knowledge of the treatment of back pain and sacroiliac joint dysfunction. Currently, these physical therapists are two out of only four in the state of Minnesota with the advanced C2 certification, allowing for the treatment of a patient who have undergone spine surgery. Primary care providers who refer will receive progress updates and are welcome to reach out for more information. Referrals may be made by phone 612-596-6105 or fax 612-596-6102.

 The beginning weeks and months of a new year often give way to moments of reflection and preparation. I have taken a moment to look back on 2018.  With abundant optimism, I am recalibrating for upcoming opportunities and challenges ahead in 2019.  At our last meeting of 2018, the MNAAP board members reviewed the 2019 legislative priorities.  These priorities include reducing vaccine-preventable disease, promoting pediatric mental health services and expanding health care access.  The board had a more specific and robust discussion as we talked about Minnesota’s provider tax, which will expire on Jan. 1, 2020, per legislation enacted in 2011. The revenue from this tax is deposited into the Health Care Access Fund, which supports insurance for lower-income Minnesotans.  In a nutshell, if the provider tax expires, many of our patients and families who are just barely getting by will lose their health insurance.  After our discussion, the board members upheld that unless there is a viable alternative to replace this source of revenue, the chapter will advocate for repealing the sunset of the provider tax. Looking back, it is clear the chapter and foundation were busy in 2018. Recently, we submitted our annual report to AAP, which contains detailed descriptions of advocacy efforts, education, and grant projects.

Here are a few outcomes from 2018 that made me         particularly proud:

Trainings educated 235 people about addressing    poverty and disparities in the clinic through webinars and in-person meetings.

Our chapter was asked to provide testimony in support of gun safety legislation and over 40 pediatricians participated in gun violence rallies and meetings over the year.

A quality improvement project at two Minnesota clinics increased up-to-date HPV immunization status for about 400 patients, from 9 percent to 74 percent.

Dovetailing into an opportunity for advocacy, I invite you to attend the upcoming Pediatricians’ Day at the Capitol on Wednesday, March 6.  This is an energy-infused activity where community pediatricians, residents, and medical students have a unique opportunity to learn more about health issues that impact the children of Minnesota. You can speak up and address priority topics with your legislator.  Let’s join together and #PutKidsFirst.

Lori DeFrance, MD, FAAP
MNAAP President
lori.defrance@essentiahealth.org

The 2019 legislative session began with a crack of the Speaker’s gavel at noon on Tuesday, Jan. 8. Families of members joined them for the traditional pomp and circumstance that mark the beginning of a legislative session.

Legislators returned to a different Capitol, with several new faces and personalities. The DFL bucked history and successfully held the governor’s office thanks to former U.S. Rep. Tim Walz’s win. Even more surprising from many analysts’ perspectives, the House DFL flipped nearly 20 seats – many in the suburbs traditionally controlled by the GOP – to pick up control of the body.  While state senators were not on the ballot this year (all 67 seats will be on the ballot in 2020) a single special election for a Senate seat was retained by the GOP and with it their one-vote majority.

Given that 2019 is the first year of the biennium, the major task before legislators this session will be consideration of a two-year biennial budget. The legislature’s task has been made a bit easier thanks to an expected budget surplus of nearly $1.5 billion.  While an eye-popping figure and cause for cheer, legislators would be well served to note that the budget forecast does turn sour in subsequent years given anticipated spending increases and a cooling economy. The governor will be unveiling his budget proposal by mid-February, and the House and Senate will begin crafting their own versions shortly thereafter.

The scheduled repeal of the provider tax is likely to be the dominant health care debate at the Capitol in 2019. The provider tax, first levied in 1994, is a tax on the gross receipts of most health care providers and serves as the chief funding mechanism for Medical Assistance, MinnesotaCare, and a number of other health care access and public health programs. Its sunset was the result of a budget agreement from 2011.  Governor Walz and House Democrats are supportive of repealing the sunset, while Senate Republicans have generally indicated their opposition to any new revenue, including repeal of the sunset. Other health care advocates have proposed alternatives to the provider tax.

It’s also likely that Governor Walz and House DFLers will also press to allow more individuals to purchase MinnesotaCare, the state’s health insurance program for many low-income Minnesotans.

The Senate GOP has been quite skeptical of these proposals in recent years.

With input from MNAAP committees, survey results from polling of members, the political climate at the Capitol, and the chapter’s historical positions on various issues, the MNAAP board has selected four priorities for the 2019 session:

Reducing gun violence.  Far too many Minnesotans have been impacted by firearm violence, and yet even common sense measures have been difficult to enact. MNAAP will continue its vocal support for expanded background checks, “red flag” laws to allow law enforcement authority to seize guns if the gun owner has been acting suspiciously, and expanded public health research into gun-related violence.   

Extending the provider tax. Preserving and expanding access to care has been a central priority for MNAAP for decades.  To that end, MNAAP opposes the sunset of the provider tax unless a viable alternative can be found.

Strengthening Minnesota’s vaccine laws. Minnesota’s vaccine laws are among the weakest in the nation.  As such, MNAAP will work with partners to strengthen our immunization laws and ensure parents have access to medically accurate information.

Increasing behavioral health care access.  All too often, pediatricians and families alike are struggling to find resources to help children with mental illness. MNAAP will partner with allies across the Capitol to support efforts to expand access to these critical services.

While MNAAP has identified four legislative priorities, the chapter will be engaged on dozens of issues.  Efforts to raise the minimum age to purchase tobacco to 21 have been successful in cities and counties across the state, and advocates – including MNAAP – will be lobbying for a statewide law increasing the age. MNAAP will also work closely with others to invest in efforts to invest in early brain development, as well as supporting a growing coalition formed to prohibit the use of “conversion therapy” with LGBTQ youth and young people.

Pediatricians have exceptional credibility at the Capitol, and it’s imperative that you exercise your voice on behalf of the state’s most vulnerable young people. MNAAP’s goals for the 2019 session are bold, and our success will depend on an active and vocal chapter.  Make plans to join the Pediatricians’ Day at the Capitol on March 6, send your elected officials an email or letter, or simply pick up the phone to let them know you’ll be watching how they vote on these critical issues.

By Eileen Crespo, MD, FAAP, Pediatrician at Hennepin Healthcare and Vice President of Medical Services at Delta Dental of Minnesota

Eileen Crespo, MD, FAAP, recently returned from a trip to the United States – Mexico border to provide medical attention to migrants awaiting admission to the U.S. She offers this reflection of her experience to Minnesota Pediatrician.

I recently traveled to the Tijuana border shelters as part of the Minnesota Caravan Solidarity Group. The group was made up of three physicians (one pediatrician — yours truly — a med-peds physician and an adult neurologist), one nurse, two medical students, a diabetes clinic community health worker, and a retired child psychiatry nurse. It was a rag-tag team of volunteers who could get away on minimal notice for an intense, long weekend. Some in the group had done international medical volunteer work in the past but this was a unique situation. We’d seen reports that the Mexican people weren’t excited to “host” the group and there had been some backlash. So, we left feeling some anxiety about the conditions of the migrants and the general situation we might find ourselves.

We arrived in San Diego and were met by an amazing coordinator. Phil Canete is a math teacher during the week, but on weekends, he volunteers with San Diego Border Dreamers organizing medical volunteers, mostly from California. We were the first team from Minnesota. Phil communicates with the multiple shelters housing migrants and arranges the volunteer groups who are then deployed to provide care.

We saw common illnesses: coughs, colds, gastroenteritis, one likely case of influenza and a probable case of strep throat. The adult providers saw uncontrolled diabetes, hypertension, and headaches. The group saw a few unusual things, such as a severe eye infection in an adult, young siblings with a rare genetic metabolic abnormality (previously identified when the family had lived in California), and I saw one case of extensive varicella, something I haven’t seen since my University of Minnesota residency in the early 1990’s. And, we saw contagious conditions such as lice and scabies. The scabies issue was particularly vexing since it was already spreading at an encampment where environmental control was not possible.

We were most troubled, however, with the widespread mental health issues. This was reminiscent of what some in the group had experienced when we traveled to Puerto Rico in the aftermath of Hurricane Maria in 2017. In Tijuana, we saw stress and anxiety in both adults and children. One notable example was a little girl who refused to eat without her mother present for fear she might be separated and never see her mother again. It’s not difficult to imagine the pervasive stress and anxiety given the long, arduous journey from Honduras, mostly by foot, and the ongoing uncertainty that continues since they’ve arrived at the United States border. The entire trek is estimated to have been 2,700 miles and many had walked for three months or more to be met by a literal and figurative wall.

“…a little girl…refused to eat without her mother present for fear she might be separated and never see her mother again.”

We learned that claiming asylum is a human right through international law. Asylum seekers must have credible fear of persecution or torture in their home country that precludes their return.  Asylum seekers can remain in the country where they are applying while their asylum application is processed.  Migrants arriving at the border claiming asylum need to meet with an immigration judge. But we learned that immigration judges are overwhelmed by the sheer numbers, so migrants are waiting weeks to months. Many migrants shared harrowing stories about the conditions in their home country including gang violence, widespread corruption and a violent drug culture.

Our group was glad to get back safely. However, we are saddened by the ongoing negative characterization of the migrants and the injustice of delaying asylum claims. We are planning future missions and will tailor our teams to provide more psychologic resources based on our observations during this first trip. We will continue to monitor the situation as another migrant caravan is heading toward the U.S. border and is estimated at more than 10,000 people. They may need our help.

By Nathan Chomilo, MD, FAAP, Park Nicollet Health Services/HealthPartners; Krishnan Subrahamanian, MD, FAAP, Hennepin Healthcare

When it comes to education, health, and economic outcomes, Minnesota remains a national leader, ranking the 4th best state for children in America. Yet that success is not uniformly distributed and is too frequently unrealized by children living in low-income households, children of color and, American Indian children. These are the findings of the 2018 KIDS COUNT report published by the Children’s Defense Fund with support from the Annie E. Casey Foundation.

At the State Capitol, businesses can point to data on unemployment and GDP, energy companies can talk about energy utilization and pollution rates, and lawyers, prosecutors, and police can talk about crime rates, incarceration and recidivism. For lawmakers seeking out objective data on the state of children in the country, and their specific county, the Annie E. Casey Foundation’s KIDS COUNT project has become a welcome tool to track benchmarks for child well-being in the United States.

In Minnesota, the Children’s Defense Fund (CDF), annually helps to compile and distribute this information. The 2018 Minnesota KIDS Count data book focuses on critical areas of childhood needs including safe and supportive homes and communities, high-quality early childhood and K-12 education, economic well-being and health coverage and care. The report not only provides raw data, but in each general category also provides policy recommendations

Since implementation of the Affordable Care Act (ACA), there has been a 60 percent decline in the number of uninsured children in Minnesota. However, we continue to see a picture of two Minnesotas in the data: between 2009-2016 three times as many American Indian children were uninsured as were white children. Hispanic and Latino children were far less likely to have had insurance during this time with an uninsured rate of greater than 10 percent. Five times as many American Indian and African American children live in poverty, and more broadly American Indian and African American families in Minnesota are over 20 times more likely to live in an area of concentrated poverty.

To help address these inequities, the report recommends health policy solutions that are largely in line with the MNAAP’s 2019 legislative priorities including expanding access to coverage regardless of immigration and residency status. Also important are expanding home visiting for vulnerable families, expanding access for dental coverage, and extending the provider tax that provides funds for vulnerable children through the Health Care Access Fund. Further policy recommendations in the report were made around emphasizing targeted outreach and enrollment efforts for American Indian and Latino communities. The report also highlighted a program at Children’s Minnesota called Community Connect which proactively helps families address social determinants of health such as food insecurity, housing, and childcare.

Outside of health care, there were several recommendations to address economic and educational disparities. The report cites evidence that even a relatively small gain in annual family income of $1,000/year can improve a child’s chance at success. To address this, the report calls for support of paid family leave, creating a state child tax credit and greater funding of the child care assistance program, early learning scholarships, Head Start and voluntary pre-K. Furthermore, the report emphasizes greater cultural competency and funding for programs that aim to serve young students of color. Regarding K-12 education, recommendations included emphasizing programs that promote school attendance, hiring more teachers of color, and increasing resources to high-quality summer and after-school programs.

With discussion of repealing the ACA taking place once again, and many of these policies coming before the Minnesota legislature this session, this report provides a solid basis from which to make educated, effective and equitable policy. A great deal more data is available, and searchable at www.datacenter.kidscount.org and county level fact sheets are available at www.cdf-mn.org.

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